- 

- 

■istory  Boom 


Division  of  Health  Affairs 
Library 

THE  UNIVERSITY  OF 
NORTH  CAROLINA 


this  book  presented  by 


Dr.  Lytt  I.  Gardner 


History  Room 


This  BOOK  may  be  kept  out  TWO  WEEKS 
ONLY,  and  is  subject  to  a  fine  of  FIVE 
CENTS  a  day  thereafter.  It  is  DUE  on  the 
DAY  indicated  below: 


MAY 


LECTURES  IN  PEDIATRICS 


TO  THE 


NORTH  CAROLINA 
POST-GRADUATE  COURSE 

1916 


By 

JESSE  ROBERT  GERSTLEY,  M.D. 
Assistant  in  Pediatrics.  Northwestern  University 
Medical  School,  Chicago 


Associate  Attending  Pediatrician.  Michael  Reese  Hospital 


LECTURE  I 


3 


MILK 

Gentlemen,  in  coming  down  to  Korth  Carolina,  this 
summer,  to  discuss  with  you  the  subject  of  children’s 
diseases,  I  have  been  confronted  with  a  serious  prob¬ 
lem.  To  cover  thoroughly  the  entire  field  of  Pediatrics 
in  thirteen  lectures  is  obviously  impossible.  To  skim 
over  it  superficially  would  leave  you  only  with  false 
impressions,  would  be  worse  than  useless,  and  would 
do  more  harm  than  good.  In  attempting  to  plan  the 
course,  I  thought  it  might  be  wiser  to  devote  most  of 
our  time  to  those  subjects  in  which  ignorance  or  lack 
of  experience  of  the  physician  leads  to  the  greatest  in¬ 
jury  to  the  patient.  Probably  in  no  other  field  of  medi¬ 
cine  are  more  terrible  mistakes  made  than  in  the  field 
of  infant  feeding  and  infant  nutrition.  Most  terrible 
misfortunes  are  brought  upon  infants,  due  to  mistakes 
or  to  ignorance  of  some  of  the  simplest  rules  of  feeding 
and  hygiene.  Indeed,  one  might  almost  say  that  if  we 
have  mastered  the  subject  of  infant  feeding  in  its  larger 
aspect,  in  addition  to  a  little  hygiene,  there  would  be  no 
sick  babies.  Don’t  take  this  statement  too  literally.  But 
I  make  it  boldly,  and  repeat  it,  to  show  you  how  much 
emphasis  I  wish  to  lay  upon  the  subject.  For  this  pur¬ 
pose  I  intend  devoting,  by  far  the  major  part  of  the 
course  to  the  consideration  of  this  fundamental  branch 
of  Pediatrics. 

If,  when  I  leave,  I  feel  that  you  have  mastered  these 
problems  thoroughly  I  shall  be  not  only  satisfied  but 
very  happy  indeed. 

In  the  clinics  following  the  lectures  we  probably  shall 
see  and  discuss  some  of  the  more  familiar  problems.  If 
at  any  time  you  have  any  suggestions  to  make  or  would 
prefer  other  subjects  to  be  considered,  I  shall  be  very 
glad  to  hear  from  you. 

In  the  lectures  upon  infant  feeding  and  nutrition, 
those  of  you  who  read  German  will  find  that  I  am 
following  rather  closely  the  teachings  and  viewpoints 
developed  by  the  Finkelstein  clinic  and  its  converts. 
I  also  am  going  to  take  the  liberty  of  including  in  these 


4 


discussions  points  advanced  by  other  clinics;  may  at 
times  venture  to  criticise  some  of  these  views  on  the 
basis  of  my  own  experience  since  returning  to  this  coun¬ 
try,  and  occasionally  shall  insert  ideas  of  my  own.  We 
of  the  Middle  West  are  not  un-American — by  no  means; 
don’t  misunderstand  me;  we  have  absolutely  no  objec¬ 
tion  to  the  percentage  system  of  feeding.  It  undoubt¬ 
edly  gives  good  results  in  the  hands  of  men  used  to  it; 
but  we  are  also  glad  to  recognize  and  incorporate 
into  our  teachings  any  methods,  be  they  American, 
German,  French,  or  English,  that  will  aid  us  in  treating 
sick  and  suffering  children ;  and  we  believe  these 
methods  that  I  am  about  to  teach  you  are  simpler  to  use, 
simpler  to  teach,  and  founded  upon  broader  conceptions 
than  the  older,  more  conservative  teachings. 

MILK 

When  a  substitute  is  wished  for  breast  milk,  there 
is  one,  and  only  one,  substitute  that  we  should  offer, 
and  that  food  is  a  mixture  of  cow’s  milk.  No  more 
terrible  injustice  is  done  to  a  child  than  failure  of  a 
physician  to  recognize  or  know  this  truth.  No  matter 
what  advertisements  you  read;  no  matter  what  claims 
are  made  for  proprietary  foods,  absolutely  no  substitute 
can  be  found  for  cow’s  milk.  In  view  of  the  impor¬ 
tance,  then,  of  this  food,  let  us  devote  ourselves  this 
morning  to  a  rather  careful  study  of  it,  studying  it 
from  the  viewpoint  of  its  chemistry,  bacteriology,  and 
its  physical  qualities. 

After  my  emphasizing  the  importance  of  cow’s  milk  as 
a  food,  all  the  more  striking  must  be  the  statement  of 
Prof.  M.  J.  Rosenau  (the  eminent  professor  of  prevent¬ 
ive  medicine  at  Harvard),  from  whose  writings  on  milk 
I  now  rather  extensively  quote,  that  milk  is  responsible 
for  more  sickness  and  more  deaths  than  all  other  foods 
combined.  Gentlemen,  just  think  of  what  this  state¬ 
ment  means.  The  one  food,  next  to  breast  milk  in  qual¬ 
ity,  is  responsible  for  more  deaths,  not  than  any  other 
food,  but  than  all  other  foods  combined !  And  it  is 
this  food  that  we  must  feed  our  babies. 

According  to  Rosenau,  the  reasons  for  this  statement 
are  four: 

a.  Milk  is  an  ideal  culture  medium  for  bacteria. 
They  grow  very  well  in  it. 


5 


b.  It  is  the  most  difficult  of  all  foods  to  handle  and 
to  deliver. 

c.  It  is  the  most  decomposable  of  all  foods. 

d.  It  is  the  only  standard  article  of  diet  obtained 
from  animal  sources  used  raw.  When  one  stops  to 
think  how  we  cook  meat,  eggs,  boil  soups  and  cook  all 
animal  foods,  it  is  surprising  that  we  still  use  milk  in 
raw  form. 

COMPOSITION  OF  MILK 

Milk  is  composed  of  five  elements  of  food — not  three, 
as  we  were  wont  to  consider,  but  five.  These  five  are: 
protein,  fat,  carbohydrate,  salts,  and  water.  It  is  the 
salts  and  water  that  are  so  frequently  overlooked  in  the 
feeding  of  children  and  in  the  treatment  of  nutritional 
disturbances,  and  which  are  of  such  importance.  We 
shall  hear  more  of  these  later. 

Protein  is  the  substance  which,  in  connection  with 
salts,  gives  structure  to  the  tissues.  Protein  is  com¬ 
posed  in  a  general  way  of  carbon,  oxygen,  hydrogen, 
and  nitrogen.  When  we  speak  of  nitrogen-containing 
foods,  we  mean  protein  in  distinction  to  the  fats  and 
carbohydrates,  which  contain  only  carbon,  oxygen,  and 
hydrogen.  Protein  in  the  milk  is  not,  as  you  may  think, 
a  specific  element,  but  consists  of  two  kinds,  viz.,  casein, 
and  albumins  and  globulins. 

Casein  is  the  substance  that  forms  thick  curds  when 
milk  is  coagulated.  The  curds  in  buttermilk  are  of 
casein,  and  it  is  this  casein  that  is  the  most  important 
form  of  protein  from  our  standpoint  of  infant  feeding. 

Albumins  and  globulins  are  the  substances  that  form 
a  scum  on  top  of  the  milk  when  it  is  boiled.  Up 
to  the  present  time  we  have  always  thought  them  unim¬ 
portant  as  regards  feeding. 

Fat  exists  in  the  milk  as  an  emulsion  of  fat  droplets. 
As  a  food,  fat  is  of  value  in  supplying  some  energy  to 
the  body,  and  is  also  stored  up  in  the  warehouses  of  the 
tissues.  It  is  the  most  variable  constituent  of  the  milk. 
The  first  milk  of  the  nursing  or  of  the  milking  is  the 
poorest  in  fat.  The  last  milk  of  the  nursing  or  of  the 
milking  is  the  richest  in  fat.  Fat  varies  in  the  milk 
of  different  animals.  Jerseys  and  Guernseys  contain 
more  than  Holsteins,  and,  not  infrequently,  a  baby 
who  is  vomiting  can  be  cured  by  changing  from  a 
Guernsey  to  the  milk  of  a  Holstein. 


6 


Carbohydrate  in  milk,  commonly  known  as  sugar  of 
milk,  is  technically  called  lactose.  Carbohydrate  is  of 
value  in  supplying  energy  to  the  body.  Like  casein, 
lactose  is  found  only  in  the  mammary  glands  and  no¬ 
where  else  in  nature.  When  bacteria  attack  lactose  it 
is  usually  changed  to  lactic  acid,  this  being  the  acid  that 
is  formed  in  buttermilk;  so  buttermilk  is  simply  milk 
from  which  the  fat  has  been  removed  and  the  sugar 
changed  to  lactic  acid. 

Salts. — The  salts  are  of  value  in  furnishing  structure 
to  the  tissues  in  connection  with  casein,  and  are  vitally 
concerned  in  many  of  the  nutritional  disturbances.  We 
shall  hear  of  them  later. 

Water  is  perhaps  the  most  important  element  in  the 
body,  being  the  universal  solvent  and  constituting  the 
greatest  proportion  of  the  body  tissues. 

Besides  these  above  substances,  a  great  variety  of 
drugs  are  found  in  milk,  and  also  some  ferments.  From 
the  standpoint  of  medicine,  however,  the  great  varieties 
of  drugs  excreted  in  milk  are  unimportant,  because  they 
are  rarely  of  sufficient  quantity  to  have  any  effect  upon 
the  child.  One  exception  may  be  made,  however,  to  the 
milk  of  cows  that  have  eaten  poisonous  weeds  and 
grasses. 

ADULTERATION  OF  MILK 

If  you,  gentlemen,  are  interested  in  the  study  of 
children’s  diseases,  you  will  frequently  be  asked  the 
ways  in  which  milk  is  adulterated.  The  most  common 
methods  employed  are  skimming,  watering,  adding 
thickening  agents  and  preservatives.  You  may  be  asked 
what  methods  are  employed  in  the  determination  of 
these  adulterations.  In  examining  milk  from  this  view¬ 
point,  we  have  three  means  at  our  disposal : 

a.  Simple  inspection. 

&.  Bacteriological  methods. 

c.  Chemical  methods. 

The  method  that  I  would  recommend  to  you — which 
is  so  simple  that  anybody  could  do  it — is  that  of  inspec¬ 
tion.  Simply  take  the  milk  and  look  at  it.  Here,  of 
course,  you  can  detect  any  gross  changes,  and  then  filter 
it  through  a  piece  of  cotton  placed  in  a  little  funnel. 
Heating  the  milk  makes  it  filter  more  easily.  On  this 
cotton  you  will  find  a  stain  varying  from  light  brown 


7 


to  black,  depending  upon  tbe  amount  of  dirt  in  tbe  milk. 
Looking  at  tbe  cotton,  one  finds  all  sorts  of  things: 
cow’s  hairs,  manure  and  feces,  scales  of  her  skin,  sand, 
straw,  and  food.  It  is  well  to  remember  that  a  wise  milk 
dealer  sometimes  filters  the  milk  before  selling  it. 

The  only  chemical  test  that  I  would  recommend  to 
you  is  the  Babcock.  This  requires  a  special  apparatus, 
but  those  of  you  who  are  interested  in  this  subject  may 
at  some  time  wish  to  have  one,  or  to  put  one  into  your 
hospital.  It  is  a  quantitative  test  for  fat.  This  is  the 
technique : 

Take  17%0  cubic  centimeters  of  milk. 

17%0  cubic  centimeters  of  sulphuric  acid. 

2  cubic  centimeters  of  amyl  alcohol. 

I  give  you  these  in  the  Metric  System,  for  the  tubes 
are  graduated  that  way.  Remember  that  30  cubic  cen¬ 
timeters  equal  1  ounce;  so  that  we  are  using  approxi¬ 
mately  one-half  ounce  each  of  these  mixtures.  Cen¬ 
trifuge  for  four  minutes;  then  add  boiling  water  to 
bring  the  fat  up  into  the  graduated  neck  of  the  tube; 
centrifuge  for  two  minutes  and  read. 

Other  chemical  methods  and  bacteriological  methods 
require  special  training. 

DIFFERENCE  BETWEEN  COw’s  MILK  AND  BREAST  MILK 

In  considering  the  subject  of  cow’s  milk,  it  is  of  im¬ 
portance  that  you  understand  the  difference  in  the  com¬ 
position  of  cow’s  milk  and  breast  milk.  A  proper  under¬ 
standing  of  this  is  absolutely  essential  to  the  feeding  of 
infants  and  is  the  basis  of  all  our  methods  of  treatment. 
Let  me  give  you  this  little  table,  which,  though  not  abso¬ 
lutely  accurate,  still  is  sufficient  for  all  practical  pur¬ 
poses: 


• 

Breast  Milk 

Cow's  Milk 

Protein . 

4% 

Pat  . 

.  4% 

4% 

Carbohydrate  . 

.  6% 

4% 

Salts  . 

.  0.2% 

0.7% 

Water . 

. 88.0% 

87.0% 

This  makes  an  easy  way  of  carrying  these  numbers 
in  your  head;  breast  milk  being  2  4  6;  cow’s  milk 
being  4  4  4.  Looking  at  this  table,  one  gets  the  im- 


8 


pression  that  the  only  difference  between  the  two  milks 
is  in  the  amount  of  the  different  constituents.  This, 
however,  is  not  the  case. 

Protein,  as  you  remember,  exists  in  the  milk  as  two 
different  elements :  casein,  and  albumin  and  globulin. 
The  proportion  of  these  two  elements  in  the  milks  is 
entirely  different. 

Protein  of  cow’s  milk  contains : 

Casein  85  -f-  per  cent.  Albumins  and  globulins  14  -f-  per  cent. 

The  protein  in  the  breast  milk  consists  of: 

Casein  61  -f-  per  cent.  Albumins  and  globulins  38  -J-  per  cent. 

To  emphasize  this  all  the  more,  let  us  look  at  their 
weights.  If  we  take  100  grams  (that  is,  a  little  over 
3  ounces)  of  milk,  and  weigh  these  different  proteins, 
we  find: 

Cow's  Milk  Breast  Milk 

Casein .  2.7  grams  0.8  grams 

Albumins  and  globulins. . .  0.2  grams  0.6  grams 

You  see  what  a  preponderance  of  casein  there  is  in 
cow’s  milk;  and,  now,  in  addition  to  this  difference  is 
also  a  difference  in  the  caseins  of  the  mixtures  them¬ 
selves.  Cow’s  milk  casein  precipitates  in  firm,  thick 
curds ;  breast  milk  casein  forms  only  the  finest  curds — 
sometimes  none  at  all;  and  cow’s  milk  casein  contains 
much  more  phosphorus  than  breast  milk  casein.  I  em¬ 
phasize  these  differences  to  show  you  how  futile  it  is  to 
attempt  to  modify  cow’s  milk  so  as  to  make  its  protein 
identical  to  that  of  breast  milk. 

As  far  as  we  know  at  present,  the  composition  of 
breast  milk  cannot  be  definitely  influenced  by  diet, 
other  than  that  a  poorly  nourished  woman  who  secretes 
little  milk  may  perhaps  be  made  to  produce  larger  quan¬ 
tities  by  building  up  her  nutrition. 

7y  at.  Like  the  proteins  of  the  two  mixtures,  the  fats 
are  of  somewhat  different  chemical  composition.  The 
fat  of  cow  s  milk  contains  more  of  the  irritating  lower 
atty  acids,  ot  which  butyric  acid  is  an  example,  and 
there  may  also  be  some  biological  variations. 

Carbohydrates,  so  far  as  we  know,  show  few  differ¬ 
ences. 


9 

Salts. — Like  the  protein  and  the  fats,  there  is  a  great 
difference  in  the  salt  content  of  the  two  mixtures,  not 
only  in  quantity  but  in  quality.  Those  in  cow’s  milk 
are  chiefly  calcium  and  magnesium.  Those  in  breast 
milk  are  chiefly  sodium  and  potassium.  And  so  you 
see  we  cannot,  in  any  simple  way,  modify  cow’s  milk 
so  as  to  make  its  salt  content  identical  to  that  of  breast 
milk.  I  emphasize  this  because  we  shall  hear  much 
more  of  these  salts  later. 

BACTERIAL  GROWTH  IN  MILK 

In  feeding  an  infant  cow’s  milk,  we  frequently  over¬ 
look  the  rapid  growth  of  bacteria  that  may  have  taken 
place  in  it,  if  this  milk  has  not  been  properly  cared  for. 
Even  if  it  has  been  kept  at  a  relatively  low  temperature, 
within  two  days  time  bacteria  will  have  multiplied  by 
millions,  and  at  warmer  temperatures  the  numbers  of 
bacteria  found  are  absolutely  incredible.  The  state¬ 
ment  impressed  me  very  much,  but  is  nevertheless  true, 
that  the  milk  we  drink  or  we  offer  to  an  infant  may 
contain  more  bacteria  than  are  contained  in  ordinary 
sewage.  Just  think  of  this,  gentlemen:  in  feeding  your 
babies  milk  mixtures,  you  may  be  feeding  them  more 
bacteria  than  are  contained  in  ordinary  sewage.  These 
bacteria  are  usually  of  the  type  attacking  the  sugar 
and  forming  lactic  acid,  thus  making  sour  milk,  but 
they  may  be  of  any  sort;  and  as  they  grow,  they  may 
produce  two  important  types  of  change : 

(1)  If  they  attack  carbohydrate  they  produce  acid, 
and  this  process  is  known  as  fermentation.  In  this 
fermentation  usually  lactic  acid  is  produced,  but  under 
certain  conditions  many  other  acids  result. 

(2)  If  they  attack  the  protein,  on  the  other  hand, 
they  produce  alkaline  products,  this  process  being 
known  as  putrefaction. 

Gentlemen,  I  urge  you  to  sharply  distinguish  between 
these  two  processes  and  remember  that  we  shall  hear  of 
these,  time  and  time  again  in  our  work,  and  you  cannot 
feed  a  normal  baby  or  you  cannot  treat  a  baby  sick  with 
nutritional  disturbance  unless  you  have  a  clear-cut  un¬ 
derstanding  of  these  changes. 

Let  me  repeat  this  once  again :  When  bacteria  attack 
carbohydrates  the  process  is  known  as  fermentation, 


10 


and  acids  result.  When  bacteria  attack  protein  the 
process  is  called  putrefaction,  and  alkalies  result. 

From  our  standpoint  of  feeding,  however,  we  must 
remember  that  the  numbers  of  bacteria  that  are  present 
in  milk  are  by  no  means  as  important  as  the  kind,  and 
this  brings  me  to  the  discussion  of  the  diseases  which 
we  know  definitely  to  be  carried  by  milk. 

MILK-BORNE  DISEASES 

Studies  have  shown  us  that  tuberculosis,  typhoid, 
diphtheria,  scarlet  fever,  dysentery,  and  many  other 
diseases  have  been  traced  definitely  to  the  milk  supply. 
A  study  made  in  Boston  some  time  ago  shows  what 
an  important  factor  milk  is  and  can  be  in  spreading 
disease,  particularly  among  children. 

In  1907,  in  Boston,  72  cases  of  diphtheria  and  717 
cases  of  scarlet  fever  were  transmitted  by  milk.  In 
1908,  400  cases  of  typhoid  were  due  to  this  cause.  In 
1910,  over  842  cases  of  scarlet  fever  were  traced  back 
to  the  milk,  and,  in  1911,  over  2,061  cases  of  septic  sore 
throat  were  again  due  to  this  same  cause.  Gentlemen, 
you  see  what  a  tremendously  important  factor  milk  is 
in  the  distribution  of  disease,  and  you  see  now  to  what 
absolutely  unnecessary  and  great  danger  we  subject  our 
babies  in  offering  them  this  food.  But  don’t  forget  that 
in  spite  of  all  these  dangers  cow’s  milk  is  by  far  infi¬ 
nitely  the  best  substitute  for  breast  milk  that  we  have. 
Cow’s  milk  may  become  infected  in  several  different 
ways:  it  may  be  directly  infected  when  obtained  from 
the  cow,  as  in  foot  and  mouth  disease,  malta  fever,  and 
milk  sickness.  In  tuberculosis,  about  2  per  cent  of 
tuberculous  cattle  have  involvement  of  the  udder,  and 
in  these  cases  the  milk  may  contain  as  many  tubercle 
bacilli  as  does  the  sputum  of  tuberculous  patients. 
Again,  the  cow  with  pulmonary  tuberculosis  coughs  up 
these  organisms,  swallows  them,  and  they  get  distrib¬ 
uted  throughout  the  manure  in  the  stable.  During 
the  milking  they  frequently  are  whisked  into  the 
buckets ;  these  buckets  of  milk  then  being  added  to  other 
buckets  of  milk  distribute  tuberculosis  throughout  the 
community.  A  study  of  market  milk  in  Chicago  in 
1910  showed  that  10.5  per  cent  of  144  specimens  ex¬ 
amined  contained  tubercule  bacilli,  as  did  16  per  cent 
of  all  specimens  of  butter  examined.  You  see,  then, 


11 


what  a  factor  milk  can  be  in  the  spread  of  tuberculosis. 
In  the  same  way  many  other  diseases  are  distributed, 
the  most  common  epidemic  attributed  to  milk  being 
typhoid.  Widespread  epidemics  of  this  disease  have 
been  reported  in  all  parts  of  the  world  and  have  been 
traced  absolutely  and  definitely  to  the  milk  supply. 
These  organisms  get  into  the  milk  as  a  rule,  not  so  much 
from  a  case  of  active  typhoid  as  from  a  so-called  typhoid 
carrier  who  works  around  the  farm,  viz.,  a  man  in  per¬ 
fect  health  who  harbors  typhoid  organisms  in  his  secre¬ 
tions. 

It  is  interesting  to  note,  by  way  of  passing,  that  more 
bacteria  are  found  in  top  milk  than  in  the  lower  layers, 
the  cream  apparently  carrying  the  bacteria  with  it. 

How  are  we  going  to  avoid  these  tremendous  dangers 
in  feeding  our  babies?  How  are  we  going  to  feed 
babies  cow’s  milk  and,  at  the  same  time,  not  make  our¬ 
selves  liable  to  the  terrible  accusation  that  we  have  in¬ 
fected  those  babies  with  tuberculosis,  typhoid,  or  dysen¬ 
tery?  There  are  at  present  three  methods  at  our  dis¬ 
posal  : 

a.  Pasteurization. 

&.  Demanding  of  certified  milk. 

c.  Boiling. 

I  am  going  to  speak  very  little  of  pasteurization,  be¬ 
cause,  if  you  are  in  no  position  to  get  certified  milk,  I 
doubt  if  a  State  pasteurization  law  would  be  a  great 
success.  Indeed,  pasteurization,  in  most  ways,  may 
do  more  harm  than  good.  Do  you  remember  that  we 
spoke  previously  of  the  changes  that  bacteria  cause  in 
milk,  and  we  said  that  when  bacteria  attack  the  carbo¬ 
hydrates,  lactic  acid  is  formed?  How,  in  the  greatest 
percentage  of  cases, of  spoiled  milk,  this  milk  has  been 
spoiled  by  fermentation  and  formation  of  lactic  acid. 
This  lactic  acid  in  itself  is  not  harmful,  but,  by  its 
presence,  it  may  prevent  dangerous  organisms,  such  as 
typhoid  or  dysentery,  from  growing  in  that  milk.  If 
we  should  pasteurize  the  milk  back  on  the  farm,  thus 
killing  off  all  the  germs  that  produce  lactic  acid,  and 
then,  after  having  done  this,  we  should  permit  a  typhoid 
bacillus  or  a  dysentery  bacillus  or  a  tubercule  bacillus 
to  get  into  that  milk,  this  organism  would  have  a  per¬ 
fectly  clear  field  for  growth.  If,  on  the  other  hand,  the 
milk  were  unpasteurized  and  it  became  spoiled,  in  the 


12 


great  majority  of  cases  the  lactic  acid  produced  might 
have  prevented  the  growth  of  these  deadly  organisms. 

So  if  you  are  not  in  a  position  to  keep  that  milk  abso¬ 
lutely  free  from  contamination  up  till  the  time  of  its 
delivery,  I  would  not  recommend  to  you  pasteurization. 

The  term  Certified  milk”  was  introduced  into  our 
literature  by  Dr.  Henry  Coit  of  Hewark,  1ST.  J.  Accord¬ 
ing  to  our  present  conception,  certified  milk  is  simply 
milk  of  the  highest  quality,  uniform  in  composition, 
obtained  from  healthy  cows,  under  the  supervision  of  a 
milk  commission.  I  should  advise  you,  gentlemen,  to 
become  interested  in  this  subject.  What  is  necessary 
is  for  all  of  you,  or  some  of  you,  to  form  a  committee 
and  enter  into  a  contract  with  a  reliable  milk  dealer. 
The  milk  dealer  must  allow  frequent  inspection  of  his 
dairy  and  frequent  analysis  of  his  milk.  The  cows 
must  be  pronounced  free  from  tuberculosis  by  a  reliable 
veterinarian,  and  must  show  a  negative  tuberculin  test. 
They  must  be  free  from  all  communicable  disease.  They 
must  be  housed  in  clean,  properly  ventilated  stables; 
the  old  wooden  walls  must  give  way  to  brick ;  the  floors 
must  be  sloping  to  allow  for  flushing  out  and  to  pre¬ 
vent  the  accumulation  of  waste.  Ho  manure  is  allowed 
to  accumulate  around  the  stalls.  All  persons  coming 
in  contact  with  the  milk  must  be  free  from  the  germs 
of  typhoid,  tuberculosis,  and  diphtheria,  and  must  ob¬ 
serve  scrupulous  cleanliness.  The  milk  must  be  drawn 
under  the  cleanest  of  conditions;  the  cows  are  washed 
before  milking;  the  tail  tied  to  the  leg,  and  the  udders 
cleaned.  The  attendants  are  usually  dressed  in  white 
and  must  themselves  observe  great  cleanliness  during 
the  milking  process.  The  milk  is  immediately  cooled, 
placed  in  sterilized  bottles,  and  kept  at  a  temperature 
of  not  over  50  degrees  until  delivered.  It  must  be  de¬ 
livered  within  twenty-four  hours  after  milking,  and 
at  that  time  may  contain  no  more  than  10,000  bacteria 
per  cubic  centimeter.  I  should  certainly  advise  you, 
gentlemen,  to  take  some  interest  in  establishing  a  cer¬ 
tified  milk  dairy  in  this  neighborhood. 

Until  certified  milk  can  be  obtained,  however,  there 
is  one  method  that  remains  to  you  for  making  the  milk 
that  you  are  feeding  your  babies  perfectly  safe,  and 
that  method  you  can  employ  right  now — this  very  ' 
day  and  that  method  is  to  boil  your  milk.  In  the 


13 


olden  times — that  is,  a  few  years  ago — when  the  science 
of  bacteriology  was  being  developed,  it  was  thought 
necessary  to  boil,  reboil,  and  again  reboil  the  milk  in 
order  to  kill  off  any  bacteria  that  it  contained,  and 
in  these  processes  changes  took  place  which  made  the 
milk  a  rather  dangerous  food.  Children  being  fed 
milk  treated  in  this  way  frequently  developed  scurvy. 
J^ow  we  know,  however,  that  if  milk  is  simply  brought 
to  a  boil,  and  boiled  gently  for  a  minute  or  two,  no  such 
danger  exists.  We  can  speak  with  absolute  assurance 
as  to  the  harmlessness  of  feeding  milk  so  treated.  Just 
look  for  a  moment  to  the  European  war  fields.  The 
men  of  France,  Austria,  and  Germany  seem  to  he 
pretty  good  fighting  men,  and  every  one  of  these  sol¬ 
diers  who,  when  an  infant,  was  not  fed  on  breast  milk, 
was  raised  on  boiled  milk.  In  these  countries  raw 
milk  is  absolutely  unknown.  So  you  see  that  very 
good  fighting  men  can  be  raised  on  boiled  milk.  If 
you  wish  to  make  yourself  entirely  safe — to  have  your 
conscience  perfectly  free — you  may  add  a  little  orange 
juice  to  the  diet  during  the  second  or  third  months,  and 
with  this  routine  I  can  assure  you  that  no  case  of 
scurvy  will  ever  develop  from  this  cause. 

Tn  the  discussion  of  boiled  milk  another  question  is 
raised  which  is  of  particular  interest  to  me,  being  a 
Chicagoan,  for  it  was  in  Chicago  that  a  very  important 
problem  along  these  lines  was  solved.  The  old  German 
pediatrician,  Biedert,  described  curds  appearing  in  the 
baby’s  stools — curds  which  were  hard,  white,  and  very 
much  like  a  lima  bean  in  appearance.  He  said  these 
curds  were  protein,  and  used  them  as  evidence  of  the 
indigestibility  of  this  element  of  the  milk.  This  view 
was  later  corroborated  by  other  observers.  The  new 
German  school,  however,  took  a  different  view  of  the 
matter.  Using  more  scientific  methods,  they  fed  chil¬ 
dren  casein,  and  found  hardly  any  increase  of  nitrogen 
in  the  stools;  and  they  argued  that  as  feeding  casein 
causes  no  increase  of  nitrogen  in  the  stool,  these  curds 
could  not  be  protein.  American  observers  then  became 
interested,  and,  if  I  remember  correctly,  Talbot  of  Bos¬ 
ton  was  one  of  those  insisting  upon  the  fact  these  curds 
did  consist  of  casein.  The  Germans  rather  scorned  this 
view,  and  claimed  that  the  American  methods  were  in¬ 
accurate.  The  Americans  replied  with  more  delicate 


14 


experiments,  using  serological  methods,  and  again 
claimed  that  these  curds  were  casein.  The  Germans 
replied  that  these  methods  were  now  too  delicate,  and 
that  the  Americans  had  identified  the  small  amounts 
of  protein  that  were  present  in  the  intestinal  juices, 
but  that  the  main  structure  of  the  curd  was  fat.  The 
controversy  waxed  quite  warm,  and  was  finally  settled 
by  Joseph  Brenneman  of  Chicago,  in  one  of  the  most 
important  pieces  of  work  that  has  been  done  in  the 
field  of  pediatrics  in  America. 

Brenneman  studied  the  cases  coming  to  the  dispen¬ 
sary  of  our  medical  college  at  home,  The  Northwestern 
University  Medical  School.  He  found  that  the  stools 
of  many  infants  contained  these  hard  curds.  Careful 
study  and  observation  showed  him  that  these  curds  fre¬ 
quently  varied  from  day  to  day — some  days  being  pres¬ 
ent,  some  days  being  absent.  Careful  questioning  of 
the  mothers  showed  that  at  times  they  boiled  the  milk, 
at  times  they  didn’t  and  continuation  of  the  study  re¬ 
vealed  the  extremely  interesting  fact  that  on  the  days 
that  milk  was  boiled  these  curds  did  not  appear  in  the 
stools.  When  the  milk  was  used  raw  the  curds  invari¬ 
ably  returned.  Here,  then,  was  the  simple  solution  of 
the  great  problem  that  had  been  vexing  Europe  and 
America.  On  the  continent,  where  raw  milk  is  un¬ 
known,  the  men  had  never  even  seen  the  casein  curds 
of  which  we  have  been  speaking,  and,  sure  enough, 
what  they  had  seen  in  the  babies’  stools  were  curds  of 
fat.  In  this  country,  with  the  previously  invariable 
use  of  raw  milk,  we  have  seen  the  true  casein  curds. 
In  Europe,  when  Brenneman  and  I  were  together, 
Brenneman  demonstrated  to  some  of  the  men  the  form¬ 
ation  of  these  casein  curds  by  giving  the  children  raw 
milk,  and  the  men  to  whom  these  experiments  were 
demonstrated  were  tremendously  interested  indeed.  So 
you  see  that  the  whole  problem  was  caused  by  our 
discussing  and  describing  different  things,  and  I  can’t 
help  thinking  that  many  of  the  great  problems  in 
pediatrics  are  probably  due  to  this  same  fundamental 
error — describing  and  talking  about  different  things. 
The  formation  of  these  curds  is  purely  a  physical  pro¬ 
cess.  It  has  nothing  to  do  with  digestion.  These 
curds  will  form  in  the  bottle  as  well  as  in  the  stomach, 
and  are  due  not  to  digestive  trouble,  hut  simply  to  shak- 


15 


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ing  of  tlie  milk  after  a  ferment  has  been  added.  If  we 
add  a  ferment  to  milk  in  a  bottle  and  shake  it  violently, 
hard,  tough  curds  will  form.  The  same  holds  true  in 
the  stomach.  If,  on  the  other  hand,  we  introduce  the 
milk  into  the  small  intestine  by  means  of  a  Hess  tube, 
thus  saving  it  the  mechanical  shaking  in  the  stomach, 
no  curds  will  form.  The  problem  of  this  curd  forma¬ 
tion,  then,  is  simply  one  of  physics,  and  is  not  of  tre¬ 
mendous  interest  to  us  from  the  standpoint  of  physi¬ 
ology. 

Our  time  is  about  up.  What  are  the  important 
points  which  we  should  and  must  remember  to  guide 
us  in  feeding  our  babies  and  treating  those  with  nutri¬ 
tional  disturbances?  Remember,  first,  the  fundamental 
differences  between  cow’s  milk  and  breast  milk ;  re¬ 
member  that  these  are  differences  not  only  in  quantity 
of  individual  ingredients,  but  also  in  quality,  and  that 
with  no  simple  means  at  our  disposal  can  we  make 
cow’s  milk  in  any  way  identical  to  breast  milk.  Re¬ 
member  that  wThen  cow’s  milk  is  not  properly  handled, 
bacteria  will  grow  in  it  at  a  tremendous  pace.  In  their 
growth  they  may  cause  two  important  changes :  If  they 
attack  the  carbohydrates  they  produce  acids,  this  proc¬ 
ess  being  known  as  fermentation;  and  if  they  attack 
protein  they  produce  alkaline  products,  this  process 
being  known  as  putrefaction.  I  urge  you,  gentlemen, 
not  to  forget  these  two  processes :  fermentation  and 
putrefaction.  We  shall  hear  them  time  and  time  again. 
Remember,  however,  that  the  numbers  of  bacteria  are 
not  as  important  as  the  kind,  and  that  milk  which  may 
be  swarming  with  lactic  acid  germs  is  not  nearly  as 
deadly  as  that  which  may  contain  smaller  numbers  of 
typhoid  or  tubercule  or  dysentery.  If  you  wish  to  have 
a  clear  conscience  in  feeding  your  babies,  if  you  wish 
to  feel  sure  that  you  have  not  been  responsible  for  giv¬ 
ing  the  baby  tuberculosis  or  typhoid  or  dysentery,  you 
must  see  that  their  milk  is  pure.  You  have  three 
methods  at  your  disposal.  The  one  of  these  I  urge  upon 
you  most  strenuously — the  one  which  you  may  employ 
today  from  the  time  you  leave  this  lecture  hall — at 
once — is  to  boil  the  milk.  In  doing  this  you  will  posi¬ 
tively  work  no  injury  to  the  child ;  you  will  change  the 
protein  so  that  no  hard  curds  will  appear  in  the  stool, 
and  you  will  protect  the  child  from  any  one  of  these 


deadly  milk-borne  diseases. 


LECTURE  II 


DIGESTION  OE  MILK 

Gentlemen,  in  the  last  lecture  we  discussed  the  sub¬ 
ject  of  milk.  Today  we  are  going  to  take  up  the  sub¬ 
ject  of  milk  and  the  baby,  considering  the  changes  in 
the  milk  due  to  the  baby  and  changes  in  the  baby  due 
to  the  milk.  In  taking  up  these  problems  this  morn¬ 
ing  we  shall  dwell  upon  the  points  in  practical  phys¬ 
iology  that  we  absolutely  must  know  in  order  to  under¬ 
stand  what  is  to  come.  Even  if  some  of  these  points 
seem  a  little  abstruse  or  a  little  impractical,  neverthe¬ 
less,  I  urge  you  to  follow  carefully  what  I  am  about 
to  say,  for  you  will  find  that  I  am  telling  you  nothing 
that  will  not  later  be  of  importance. 

PROTEIN 

The  old  idea  of  the  digestion  of  protein  was  that 
in  this  process  the  protein  simply  became  soluble. 
ISTow,  we  note  that  protein  digestion  is  a  far  more 
complicated  process,  the  protein  being  literally  torn  to 
pieces  by  the  ferments  of  the  digestive  tract.  One 
may  compare  protein  to  a  great  complicated  structure, 
such  as  a  schoolhouse  or  a  building,  which  in  the 
process  of  digestion  is  torn  apart  into  the  individual 
blocks  of  stone  (these  being  known  as  amino  acids), 
and  in  the  process  of  assimilation  these  are  put  together 
again  and  built  into  the  structure  of  the  baby’s  tissue. 
The  protein  digestion  begins  in  the  stomach  and  is 
completed  in  full  in  the  intestine. 

In  the  intestine  the  protein  performs  an  important 
function,  viz.,  large  quantities  of  alkaline  intestinal 
juice  are  required  for  its  digestion,,  and,  in  this  way, 
protein  digestion  is  associated  with  the  formation  of  an 
alkaline  reaction  in  the  intestine.  Practically  all  of 
the  protein  is  absorbed  from  the  gastro-intestinal  tract, 
particularly  when  the  milk  is  boiled.  In  the  use  of  raw 
milk  large  casein  curds  escape  digestion  and  increase 
the  nitrogen  contents  of  the  stool,  but  in  boiled  milk 
very  little  nitrogen  leaves  the  body  by  way  of  the  stool. 


17 


And  this  nitrogen  does  not  necessarily  have  to  come 
from  the  protein  of  the  food,  but  may  also  come  from 
the  protein  of  the  intestinal  juices  and  protein  of  the 
intestinal  bacteria  and  of  the  intestinal  epithelium. 
Once  past  the  digestive  tract  into  the  body,  this  food 
has  three  important  duties : 

a.  It  will  replace  protein  that  has  been  lost  from  the 
body. 

b.  It  supplies  structure  to  the  tissues  to  satisfy 
growth. 

c.  It  can  be  used  by  the  tissues  for  energy. 

It  is  an  interesting  thing  that  the  amount  of  protein 
retained  in  the  body  does  not  depend  markedly  upon 
the  amount  offered  to  the  child,  the  child  retaining 
approximately  about  the  same  amount  of  nitrogen 
whether  fed  on  the  low  protein  breast  milk  or  the  high 
protein  cow’s  milk.  When  the  protein  leaves  the  body 
it  is  excreted  practically  entirely  through  the  urine. 
About  60  to  80  per  cent  of  it  appears  in  the  urine  as 
area  and  the  remainder  as  ammonia  and  other  waste 
products. 

FAT 

As  we  said  in  the  last  lecture,  the  amount  of  fat  in 
;he  milk  varies  with  the  duration  of  nursing.  Like  the 
>rotein,  fat  digestion  begins  in  the  stomach.  Perhaps 
15  per  cent  of  the  fat  is  partially  split  up  in  the 
itomach,  the  rest  being  digested  by  the  ferments  of  the 
ntestine.  Unlike  the  protein,  however,  some  fat  nor- 
nally  appears  in  the  stool.  Whether  this  fat  has  been 
aken  into  the  body  and  then  excreted  into  the  large 
ntestine,  or  whether  this  fat  simply  passes  through 
he  intestinal  tract  undigested,  we  do  not  know,  but 
he  fact  remains  that  approximately  1  to  10  per  cent 
f  the  fat  taken  by  the  baby  in  its  bottle  will  appear 
gain  in  the  stool.  It  is  important  to  remember  that 
be  fat  that  appears  in  the  stool  is  not  necessarily  in 
be  same  form  as  it  was  when  the  baby  drank  it.  It 
ppears,  as  a  rule,  in  three  different  ways,  and  these 
free  different  ways,  gentlemen,  I  urge  you  to  note 
ecause  we  shall  hear  of  them  later.  Fat  exists  in  the 
;ool  as 

(1)  Ordinary  neutral  fat.  This  is  the  simple  fat 
lat  was  in  the  milk  as  the  baby  drank  it. 

2 


18 


(2)  It  appears  as  soap.  I  won’t  bother  you  with 
the  chemistry  of  the  formation  of  soaps,  but  in  a  crude 
general  way  remember  that  fat,  when  it  joins  alkalis, 
such  as  calcium  and  magnesium,  forms  a  soap.  This  is 
not  the  absolutely  correct  chemical  picture,  but  it  will 
suffice  for  our  purpose. 

(3)  It  may  appear  as  a  fatty  acid.  These  in  con¬ 
trast  to  soaps  are  simply  fat  in  combination  with  an 
acid .  Again,  this  is  not  strictly  chemically  correct, 
but  it  will  suffice. 

So  you  see  when  the  intestine  is  alkaline,  soaps  are 
formed,  and  when  the  intestine  is  acid  the  soaps  dis¬ 
appear  and  the  fat  becomes  changed  to  a  fatty  acid. 

The  great  majority  of  fat  that  passes  the  digestive 
tract  is  either  burned  in  the  body  or  else  is  stored  in 
the  subcutaneous  tissues  and  in  the  liver.  Fat,  in  con¬ 
trast  to  protein,  is  not  an  absolute  essential  to  the  diet. 
Some  babies  are  raised  very  nicely  on  buttermilk  or  on 
skimmed  milk  in  which  there  is  practically  no  fat, 
and  never  seem  to  suffer  from  the  "want  of  it.  However, 
some  clinical  observation  would  suggest  that  these  chil¬ 
dren  have  a  lessened  degree  of  immunity  to  infection 
than  have  the  children  on  higher  fat  diets. 

CARBOHYDRATES  OR  SUGARS 

In  taking  up  the  subject  of  carbohydrates,  we  shall 
consider  almost  the  most  important  element  of  food 
used  in  infant  feeding.  Carbohydrates  exist  in  nature 
in  three  different  forms : 

(1)  They  exist  as  the  complex  carbohydrates  of 
which  starch  is  an  example. 

(2)  They  exist  in  less  complex  forms,  known  as  di¬ 
saccharides,  of  which  lactose  (or  milk  sugar),  saccha¬ 
rose  (or  cane  sugar),  and  maltose  (or  malt  sugar)  are 
examples. 

(3)  They  exist  in  simple  forms,  of  which  glucose  or 
grape  sugar  is  a  good  illustration. 

Tt  is  indeed  an  interesting  thing  that  the  body  can 
use  carbohydrate  only  in  its  simplest  form,  viz.,  that 
form  which  glucose  represents.  If  we  should  inject  a 
solution  of  lactose  (milk  sugar)  under  the  skin,  this  very 
same  lactose  would  pass  right  through  the  body,  would 
be  absolutely  untouched  by  the  body  tissues,  and  would 


19 


ifi 


be  excreted  as  lactose  in  the  urine.  This  holds  true  for 
practically  all  of  the  other  more  complicated  sugars, 
with  the  one  exception  of  maltose.  The  cells  of  the  body 
seem  in  some  mysterious  way  to  have  the  faculty  of 
using  maltose.  So  you  see  that  the  process  of  digestion  of 
carbohydrate  is  simply  a  means  by  which  more  compli¬ 
cated  carbohydrates  are  split  down  to  form  the  simple 
ones — a  means  to  adapt  all  forms  of  carbohydrate  to  the 
use  of  the  body  tissues.  In  this  splitting  down  it  is  well 
to  remember  the  different  stages  through  which  a  com¬ 
plex  carbohydrate  like  starch  passes.  The  first  product 
is  a  substance  called  dextrin,  which  is  very  much  like 
thoroughly  browned  flour.  The  next  step  in  the  diges¬ 
tion  is  the  formation  of  maltose  and  the  last  step  the 
formation  of  the  simple  sugars,  such  as  glucose.  That 
you  may  have  a  clearer  picture  of  this  process,  let  me 
remind  you  that  the  simple  sugar  glucose  is  composed  of 
C6H1206  ;  the  disaccharides,  meaning  milk  sugar,  malt 
sugar,  and  cane  sugar,  are  composed  of  two  of  these 
simple  sugars  fastened  together;  and  the  complicated 
carbohydrates,  such  as  starches,  are  composed  of  a  great 
many  of  them  bound  together  in  different  fashions. 

Just  as  with  the  other  food  substances,  by  far  the 
greater  part  of  the  digestion  of  carbohydrates  goes  on  in 
the  intestine.  Here  they  are  split  up  to  the  simple 
sugars  and  practically  all  absorbed.  In  the  normal  baby 
one  rarely  finds  any  carbohydrate  in  the  stool.  One  ex¬ 
ception  may  be  made,  this  being  when  a  child  is  fed  a 
large  amount  of  starch.  If  the  starch  is  not  thoroughly 
iigested,  it  may  then  appear  in  the  stools. 

Having  passed  through  the  intestinal  mucous  mem¬ 
brane,  the  carbohydrates  enter  the  blood  and  are  stored 
jp  in  the  liver  and  muscles  as  glycogen,  and  from  these 
*reat  storehouses  the  amount  of  sugar  in  the  blood  is 
sept  at  practically  uniform  composition,  viz.,  0.10  per 
;ent.  The  end  products  of  the  carbohydrates  are  those 
firmed  by  burning,  and  are  chiefly  carbon  dioxide  and 
vater.  The  carbohydrate  is  practically  all  burned  and 
lever  normally  appears  in  the  urine  as  such,  unless  very, 
rery  large  quantities  are  given. 

It  is  well  to  remember  that  a  child  has  a  very  great 
olerance  for  carbohydrate,  apparently  needing  much 


20 


more  in  proportion  to  his  body  weight  than  does  an 
adult.  Just  take  this  example,  for  instance:  A  baby 
weighing  10  pounds  will  drink  approximately  800 
cubic  centimetres  of  breast  milk — almost  a  quart.  In 
this  he  gets  56  grams  of  lactose — almost  2  ounces.  If 
we  wish  to  feed  an  adult,  weighing  140  pounds,  the 
same  amount  of  sugar  in  proportion  to  his  weight, 
we  would  have  to  feed  him  800  grams  a  day — almost 
27  ounces.  So  you  see  what  tremendous  need  the  child 
has  for  sugar.  Indeed,  it  is  from  the  study  of  infant 
nutrition  and  disease  that  we  are  just  beginning  to 
learn  the  great  value  of  carbohydrate  to  the  body  and 
the  variety  of  functions  that  this  interesting  food 
performs.  Let  us  study  them  for  a  moment. 

a .  First  and  foremost,  sugars  supply  energy  to  the 
tissues.  The  baby  works  and  cries  and  performs  all 
his  daily  functions  chiefly  from  the  energy  supplied 
by  the  carbohydrate. 

b.  In  an  interesting  way,  not  thoroughly  explained, 
carbohydrate  seems  to  save  the  tissue  protein.  If  we 
feed  a  baby  a  rather  high  amount  of  sugar,  the  baby 
seems  to  live  on  this  and  use  up  less  of  his  body 
protein. 

c.  The  carbohydrate  is  related  in  a  very  interesting 
way  to  the  fat.  If  the  baby’s  body  is  not  supplied 
with  enough  sugar,  the  fat  of  the  food  becomes  almost 
poisonous  and  abnormal  split  products  appear  in  the 
urine.  When  the  carbohydrate  in  the  diet  is  increased, 
these  toxic  products  disappear.  The  old  German  clin¬ 
ician,  Haunyn,  described  these  phenomena  in  the  very 
striking  sentence :  “The  fat  burns  in  the  fire  of  the 
carbohydrates.”  Just  remember  that  sentence  gentle¬ 
men,  “The  fat  burns  in  the  fire  of  the  carbohydrates,” 
and  you  will  have  a  striking  picture  of  fat  and  car¬ 
bohydrate  metabolism. 

d.  In  contrast  to  the  fat,  sugar  in  the  diet  cannot  be 
absolutely  replaced.  Rosenstern,  one  of  Finkelstein’s  a&- 
sistants,  in  very  interesting  experiments,  showed  that  if 
sugar  is  entirely  removed  from  the  baby’s  diet  the  baby 
will  not  thrive,  and  he  proved  conclusively  that  a  baby 
to  live  must  have  a  definite  minimum  of  sugar.  So,  in 

contrast  to  the  fat,  sguar  is  absolutely  essential  to  the 
baby’s  life. 


21 


e.  We  are  just  beginning  to  learn  of  a  very  im¬ 
portant  relation  that  carbohydrates  have  to  water  in 
the  baby’s  body.  This  point  is  not  absolutely  proven. 

,  Indeed  I  have  had  some  very  heated  discussions  with 
scientists  about  this  very  subject.  The  scientists  say 
we  have  not  as  yet  proven  our  point;  but  clinical  evi- 
:  dence  is  very  strong,  and  it  is  on  the  basis  of  this 
|  clinical  evidence  that  I  ask  you  to  remember  that  car¬ 
bohydrates  help  the  baby  to  retain  water.  The  follow- 
1  ing  curve  illustrates  to  you  the  observations  which  led 


$ 

aI 

st 


A 

From  Langstein  *  -  Meyer 


if 

t 

Q' 

>1 


f,  at  point  “A,”  one  should  add  a  small  amount,  viz., 
wo  to  three  teaspoons  of  a  simple  carbohydrate  to  the 
)ottle,  not  infrequently  the  weight  jumps  up  many 
•unces.  How  are  we  to  explain  this  tremendous  rise 
n  the  curve  ?  A  baby  cannot  gain  several  ounces 
rom  a  few  teaspoons  of  food.  There  is  not  enough 
rotein,  not  enough  fat,  not  enough  carbohydrate  in  a 
sw  teaspoons  to  weigh  several  ounces.  The  logical  con¬ 
tusion  is  that  this  gain  must  be  due  to  water.  We  know 
aat  the  child  is  somewhat  like  a  sponge,  and  absorbs 
ater  into  his  tissues  and  excretes  it  again  very  readily, 
gain,  the  removal  of  a  small  amount  of  sugar  from  the 
aby’s  diet  may  lead  to  a  sharp  drop  of  5  or  6  ounces. 

/.  Sugars'  have  an  interesting  relation  to  body  tem- 
erature : 

(1)  If  the  body  is  markedly  cooled,  the  glycogen 
>,ems  to  disappear  from  the  muscles. 


22 


(2)  The  following  little  temperature  curve  will  il¬ 
lustrate  this  point  from  a  clinical  standpoint: 


This  child,  with  only  2  per  cent  sugar  in  his  diet, 
may  have  had  a  subnormal  temperature  for  several 
days.  If  we  increase  the  sugar  or  carbohydrate  to  4 
per  cent,  not  infrequently  the  temperature  rises  to 
normal. 

MINERALS 

Gentlemen,  the  mineral  matter  in  the  baby’s  food 
has  been  a  subject  long  overlooked.  Indeed,  even 
now,  the  door  is  barely  open,  but  visions  and  dreams, 
perhaps,  begin  to  suggest  to  us  the  coming  importance 
of  mineral  metabolism.  Indeed,  one  almost  may  say 
that  the  physiologists  are  learning  something  of  this 
question  from  the  pediatricians.  The  baby  is  the 
simplest  of  all  organisms  to  study.  He  is  untouched 
by  disease,  his  food  is  the  simplest  of  all  foods,  can 
be  analyzed  and  absolutely  controlled,  and  to  get  cor¬ 
rectly  his  total  urine  and  daily  stools  in  twenty-four 
hours  is  not  a  very  difficult  task.  Hence,  the  study 
of  the  baby  has  increased  our  knowledge  markedly  in 
some  of  the  fields  of  physiology. 

Of  mineral  matter,  breast  milk  has  0.2  per  cent; 
cow’s  milk,  0.76  per  cent. 

You  see  that  cow’s  milk  has  almost  four  times  the 
salt  content  of  breast  milk.  Of  practically  only  one 
salt  is  there  a  smaller  amount  in  cow’s  milk  than  in 
breast  milk,  and  that  salt  is  iron. 

Strange  that  we  have  so  long  overlooked  these  great 
differences  in  our  study  of  infant  feeding.  The  splen- 


23 


did  researches  of  Ludwig  F.  Meyer  have  been  mainly 
and  only  relatively  recently  responsible  for  bringing 
them  to  our  attention.  Like  other  foods,  salts  are 
absorbed  chiefly  from  the  intestines.  In  the  body 
they  work  great  varieties  of  functions,  and  they  leave 
the  body  through  the  kidney  and  the  bowel.  Through 
the  kidney  the  great  majority  of  salts  are  excreted; 
through  the  intestines  calcium,  magnesium,  and  iron 
leave.  Of  course,  we  cannot  say  whether  the  calcium, 
magnesium,  and  iron  that  we  find  in  the  stool  have  been 
absorbed  into  the  body  and  thrown  out  again  or  whether 
they  have  simply  passed  through  the  child’s  digestive 
tract  unabsorbed;  but  we  do  know  that  we  find  these 
salts  in  the  stool.  Let  me  just  call  attention  to  the  cal¬ 
cium  salts  in  passing  : 

One  quart  of  Breast  Milk  Cow’s  Milk 

Calcium  0.42  grams  1.72  grams 

You  see,  gentlemen,  the  preponderance  of  calcium  in 
cow’s  milk.  I  mention  this  just  by  way  of  interest  in 
passing,  for,  as  you  know,  rickets  rarely  appears  in  the 
breast-fed  baby.  Some  men  have  attempted  to  explain 
this  by  saying  that  the  baby  on  the  bottle,  due  to  insuffi¬ 
cient  calcium,  develops  rickets.  You  see  this  theory  is 
in  this  simple  form  absolutely  untenable,  because  the 
baby  is  getting  infinitely  more  calcium  on  the  bottle 
than  on  the  breast. 

In  the  normal  baby  the  salts  have  a  definite  relation 
to  the  protein,  and  for  every  definite  amount  of  protein 
that  the  baby  absorbs  into  his  tissues  the  correspond¬ 
ing  amount  of  salt  is  retained.  This  relation  is  far 
more  definite  in  the  breast  baby  than  in  the  bottle 
baby.  In  the  bottle  baby  the  salts  do  not  seem  to  be 
in  such  definite  relations  to  the  protein,  and  in  dis¬ 
turbances  often  far  more  salts  are  lost  than  is  protein. 
This  improper  relation  of  the  salt  and  the  protein 
in  the  artificially  fed  baby  may  in  a  way  be  a  feature 
in  some  of  the  disturbances. 

Gentlemen,  I  don’t  want  to  bother  you  too  much 
with  chemistry,  but  let  me  give  you  one  little  glimpse 
into  the  tremendous  possibilities  of  salt  metabolism. 
Suppose  we  take  a  simple  salt  like  calcium  chloride; 
suppose  that  salt  is  introduced  into  the  intestine.  In 
the  intestine  it  is  split  up  into  calcium  and  chlorine. 


24 


We  have  just  learned  that  chlorine  is  excreted  chiefly 
in  the  urine;  that  calcium  is  excreted  chiefly  in  the 
stool.  We  may  picture  to  ourselves  the  following  pro¬ 
cess  : 


Chlorine  cannot  leave  the  body  alone;  must  leave  in 
combination  with  some  other  salt,  and  usually  takes 
with  it  sodium.  The  calcium  makes  other  combinations 
in  the  intestines.  Thus,  by  feeding  a  little  simple 
substance  like  calcium  chloride  we  are  forcing  sodium 
out  of  the  body  through  the  urine.  This  is  just  a  simple 
conception,  hut  see  what  tremendous  possibilities  open 
to  us !  Just  picture  to  yourselves  all  the  different 
salts  of  the  baby’s  diet  pursuing  their  indi¬ 
vidual  courses  through  his  body.  Just  see  these  possi¬ 
bilities  !  We  are  barely  beginning  to  grasp  them. 
How  utterly  in  the  dark  are  we  as  to  the  real  actual 
effects  upon  the  child’s  organism  of  the  complicated 
mixtures  that  we  are  wont  to  prescribe !  We  are  barely 
at  the  beginning  of  understanding  the  true  effects  of 
our  simplest  combinations,  and  you  can  see  what  enor¬ 
mous  differences  absolutely  unknown  to  us  must  there 
be  in  the  effects  upon  the  child’s  body  of  the  markedly 
different  salt  content  of  breast  milk  and  of  cow’s  milk. 

Like  protein,  water,  and  carbohydrates,  minerals  are 
.absolutely  essential  to  life,  and  removal  of  them  results 
in  rapid  death.  The  fascinating  experiments  of  J acque 
Loeb  show  that  not  only  are  minerals  absolutely  essen¬ 
tial  to  life,  but,  if  they  are  not  present  in  the  body  in 
certain  proportions ,  they  may  exert  toxic  influences. 
To  the  eggs  of  certain  sea  animals  solutions  of  salt 
water  are  infinitely  more  poisonous  than  are  solutions 
of  distilled  water,  and  this  poisonous  quality  can  be 
reduced  by  adding  to  the  solution  definite  quantities 
of  potassium  and  calcium.  The  surgeons  make  use  of 
these  principles  in  their  so-called  balanced  salt  solu- 


25 


tions.  Like  carbohydrate,  salts  seem  to  have  definite 
relation  to  body  weight  and  temperature : 


The  removal  of  the  salts  in  this  particular  instance 
at  point  “A”  results  in  a  drop  of  temperature  and  a 
marked  loss  of  weight.  The  most  important  of  all 
salts  apparently  in  causing  these  effects  is  sodium. 
Again,  in  chronic  undernutrition,  with  deficiency  of 
salt  in  the  diet,  the  temperature  may  be  consistently 
subnormal,  and  feeding  a  child  in  this  stage  about  a 
dram  of  sodium  chloride  may  cause  a  marked  rise  in 
the  temperature,  with  fever. 

WATER  METABOLISM 

The  child’s  tissues  are  somewhat  richer  in  water  and 
the  demands  for  it  greater  than  in  the  adult.  If  the 
child  drinks  a  quart  of  breast  milk  a  day — a  quart  be¬ 
ing  equal  to  1,000  c.c. — he  drinks  885  c.c.  of  water. 
Just  see  the  enormous  percentage  of  water  in  the  baby’s 
diet — 885  parts  to  every  1,000— or,  to  put  it  differently: 
an  adult  uses  approximately  one-half  ounce  of  water 
for  every  pound  that  his  body  weighs,  while  the  child 
uses  between  2  and  3  ounces  of  water  for  every  pound 
of  body  weight — almost  four  times  the  quantity  of 
the  adult.  Like  the  other  foodstuffs,  water  is  absorbed 
chiefly  from  the  small  intestine.  It  is  stored  mainly 


26 


in  the  muscles  and  normally  it  leaves  the  body  about 
60  per  cent  through  the  urine  and  about  40  per  cent 
through  the  lungs  and  skin. 

We  have  spoken  previously  about  the  relation  of  car¬ 
bohydrate  and  salts  to  water.  Let  me  remind  you  of 
this  important  fact  once  more,  by  the  following  curve: 


If,  at  point  “A,”  we  should  add  a  teaspoon  of  salt 
to  the  diet,  the  baby’s  weight  would  rise  sharply  and 
rapidly.  The  inexperienced  physician  and  the  happy 
mother  might  exclaim :  “At  last  we  have  found  the 
proper  diet!  The  child  is  now  finally  gaining!”  But, 
unfortunately,  after  five  days,  a  withdrawal  of  this  same 


27 


salt  would  cause  just  such  precipitate  a  drop  in  the 
baby’s  weight  as  it  previously  caused  a  rise.  The  weight 
would  come  down  just  exactly  to  where  it  had  been  be-r 
fore  the  salt  was  added,  and  now  would  we  rather  rue¬ 
fully  learn  that  this  great  gain  of  the  baby  was  not  a 
true  gain  of  tissue  substance,  but  was  only  a  gain  in 
water  content  of  the  body.  In  all  our  dealings  with 
babies,  let  us  not  forget  that  in  his  great  ability  to  ab¬ 
sorb  and  squeeze  out  water  the  baby  greatly  resembles  a 

I  sponge. 

MILK  IN  THE  GASTRO-INTESTINAL  TRACT 

Gentlemen,  we  have  considered  the  individual  ele¬ 
ments  of  the  milk.  We  have  considered  them  in  the 
process  of  digestion  in  the  gastro-intestinal  tract;  we 
have  followed  them  through  the  body ;  we  have  followed 
them  in  their  excretion.  Let  us  pause  for  a  moment 
and  look  at  the  picture  of  the  milk  as  a  whole. 

In  the  stomach  two  important  changes  take  place: 
the  protein  of  the  milk,  due  to  the  rennet  ferment, 
coagulates,  and  the  milk  separates  into  the  curd  and 
the  whey.  You  remember  that  the  curd  consists  of  the 
casein  and  in  its  formation  it  ensnares  in  its  meshes 
some  fat.  Much  of  the  calcium  is  dragged  out  of  the 
whey  in  this  process  and  joined  in  chemical  combina¬ 
tion  to  the  casein;  so  casein  in  connection  with  the 
base  calcium  becomes  a  powerful  agent  for  making  the 
intestine  alkaline.  The  whey,  you  will  remember,  rep¬ 
resents  the  water-soluble  elements  of  the  milk,  i.  e., 
the  water,  salts,  sugar,  and  the  albumins  and  globulins. 
This  quickly  leaves  the  stomach.  The  casein  curd 
with  the  entrapped  fat  to  be  thoroughly  digested  remains 
often  several  hours.  This  interesting  little  point  in 
physiology  explains  to  us  the  uselessness  of  following 
the  tables  which  the  older  scientists  with  great  pride 
and  perseverance  built  for  us,  viz.,  feeding  the  child  at 
definite  ages  food  in  proportion  to  the  capacity  of  his 
stomach.  As  a  matter  of  fact,  because  the  whey  leaves 
the  stomach  so  rapidly,  we  can  often  feed  the  baby 
much  more  than  we  would  imagine,  and  we  may  dis¬ 
regard  these  older  tables  entirely.  You  see  we  have 
at  our  hands  a  means  for  hastening  or  retarding:  the 
emptying:  of  a  baby’s  stomach.  A  mixture  high  in 
whey  will  leave  the  stomach  rapidly;  a  mixture  high 


28 


in  casein  and  fat  will  leave  slowly,  and  by  altering  our 
mixtures  we  can  greatly  influence  gastric  motility. 

In  the  intestine  the  milk  meets  the  various  digestive 
ferments.  The  bile  makes  the  fat  soluble.  This,  in 
addition  to  the  ferments  of  the  pancreas  and  the  in¬ 
testinal  glands,  seizes  all  the  fat,  carbohydrate,  and 
protein,  and  tears  them  down  to  their  fundamental 
elements.  Then  they  leave  the  intestine  to  enter  the 
body. 

This  in  a  very  superficial  way  describes  the  digestion 
of  the  milk.  Just  what  remains  in  the  stool?  In  the 
stool  we  have : 

a.  Great  quantities  of  bacteria.  I  put  these  bacteria 
first  because  I  want  to  impress  upon  you  how  very  im¬ 
portant  they  are  from  our  viewpoint.  Up  to  the  pres¬ 
ent,  in  infant  feeding,  the  bacteria  of  the  stool  have 
been  almost  overlooked.  They  may  at  times  be  16  to 
18  per  cent  of  the  baby’s  stool.  You  see  w7hat  tremen¬ 
dous  possibilities  there  are  for  bacterial  action  in  the 
intestine.  Normally,  these  bacteria  live  only  in  the 
large  intestine,  the  upper  intestine  being  sterile;  but, 
under  conditions  of  which  we  shall  hear  later,  these 
bacteria  leave  their  home  in  the  large  intestine,  migrate 
up  to  the  small  intestine,  and  flourish  there.  Why  they 
remain  only  in  the  large  intestine,  and  do  not  thrive  in 
the  upper  intestine,  is  not  absolutely  known.  Some  men 
claim  that  the  upper  bowel,  either  by  its  juices  or  by  the 
properties  of  its  cells,  is  able  to  exert  a  strong  bacteri¬ 
cidal  influence.  Kendall  has  suggested  to  me  that  due  to 
the  rapid  absorption  of  the  foodstuff  bacteria  may  not 
thrive  in  the  upper  intestine  normally,  as  no  food  re¬ 
mains  there  for  them.  Probably  both  factors  are  of  im¬ 
portance. 

In  the  large  intestine  two  radically  different  groups 
of  bacteria  exist;  those  living  chiefly  on  protein,  at¬ 
tacking  this  protein,  and  causing  putrefaction  and  al¬ 
kali  formation;  those  living  chiefly  on  carbohydrate, 
attacking  the  sugars  and  causing  fermentation  and  acid 
formation. 

Gentlemen,  in  our  last  lecture  you  heard  of  the 
tremendous  importance  of  these  two  processes:  fermen¬ 
tation  and  putrefaction.  Just  as  readily  as  in  the  milk 
that  stands  at  the  doorstep  do  these  two  processes  pro- 


29 


ceed  in  the  child’s  intestinal  tract;  but  here  we  have 
them  under  our  perfect  control.  Feeding  high  protein 
will  call  forth  the  putrefactive  organisms ;  feeding  high 
carbohydrate  will  call  forth  those  producing  fermenta¬ 
tion.  Remember  here  that  putrefaction,  with  its  re¬ 
sulting  alkaline  change,  slows  down  intestinal  peristalsis 
and  leads  to  an  alkaline  foul-smelling  stool.  On  the 
other  hand,  fermentation,  with  its  resulting  acid  forma¬ 
tion,  leads  to  increased  peristalsis  and  to  watery,  green¬ 
ish,  sour-smelling  diarrheal  stools.  I  urge  you,  under  no 
circumstances,  to  forget  protein  putrefies;  carbohydrate 
ferments. 

b.  Besides  the  bacteria,  the  stool  of  course  consists 
of  unabsorbed  foodstuffs : 

(1)  Protein,  we  learned  before,  rarely  appears  in 
the  stool  in  any  appreciable  quantity  normally  unless 
raw  milk  is  given. 

(2)  Fat  is  somewhat  concerned  in  the  actual  struc¬ 
ture  of  the  stool.  Feeding  skimmed  milk  often  results 
in  rather  thin  bowel  movements  with  mucus  and  small 
amounts  of  solid  material;  increasing  the  fat  in  the 
diet  may  give  rise  to  a  formed  stool.  It  is  the  fat  in 
the  form  of  soaps  which  has  most  influence  on  stool 
structure. 

(3)  Like  protein,  little  carbohydrate  is  found  nor¬ 
mally,  except  in  those  cases  where  a  high  amount  of 
starch  is  fed,  this  starch  passing  through  the  intestinal 
tract  undigested. 

(4)  The  salts  are  of  great  importance.  Calcium,  for 
instance,  by  its  insolubility  in  water,  gives  bowel  move¬ 
ments  of  dry,  alkaline  nature. 

c.  Besides  bacteria  and  the  food  substances  in  the 
stool,  we  have  the  indirect  products  of  the  food  sub¬ 
stances.  The  protein,  as  you  remember,  calls  forth  an 
alkaline  intestinal  juice,  rich  in  albumin.  Secondly,  any 
protein  or  albumin  that  is  not  absorbed  into  the  system 
through  the  intestine  will  be  attacked  by  the  putre¬ 
factive  bacteria,  and  alkaline  products  result.  In  the 
same  way  any  unabsorbed  carbohydrate  will  ferment 
into  acid  products.  The  amount  of  fermentation  of  this 
carbohydrate  we  can  influence  markedly  by  the  nature 
of  carbohydrate  we  feed.  Bacteria  do  not  attack  read¬ 
ily  the  complicated  carbohydrates,  such  as  starches  and 


30 


dextrins.  When  we  feed  starch  or  a  dextrin  to  a  baby 
this  carbohydrate  is  slowly  changed  by  the  digestive 
processes  to  the  simpler  sugars,  and  these  simpler  sugars’ 
as  they  are  formed  in  small  amounts,  are  absorbed 
through  the  upper  intestine  before  the  bacteria  can  at¬ 
tack  them.  Thus  complex  carbohydrates,  such  as  starch 
and  dextrin,  are  normally  rather  constipating.  The 
lower  carbohydrates,  such  as  milk,  sugar  and  glucose,  are 
readily  attacked  by  bacteria.  When  a  child  receives  a 
large  quantity  of  one  of  these  sugars  some  of  it  easily 
gets  down  to  the  region  where  intestinal  bacteria  are 
flourishing,  and  fermentation,  acid  formation,  and  diar¬ 
rhea  results.  It  is  an  interesting  thing  that  the  fer¬ 
mentation  of  these  sugars  is  influenced  by  several  dif¬ 
ferent  factors : 

a.  Feeding  the  baby  whey  seems  to  increase  markedly 
the  degree  of  fermentability  of  the  sugar. 

b.  An  increased  amount  of  protein  in  the  diet,  due 
to  its  putrefying  alkaline-forming  properties,  makes 
the  sugar  less  fermentable. 

c.  The  condition  of  the  intestine  is  of  great  im¬ 
portance  : 

(1)  A  perfectly  healthy  intact  mucous  membrane 
will  probably  be  able  to  keep  bacterial  growth  under 
control  and  prevent  a  marked  degree  of  fermentation. 

(2)  A  diseased  intestine  will  probably  not  be  able 
to  combat  a  fermentation  induced  by  a  high  degree  of 
sugar  feeding. 

You  see,  gentlemen,  why  I  am  dwelling  upon  these 
subjects :  The  condition  of  the  baby’s  stools  depends 
absolutely  upon  you.  You  have  in  your  hands  the 
means  of  making  the  baby’s  stool  alkaline,  constipated, 
and  hard,  or  acid,  diarrheal,  and  watery.  There  is  no 
mystery  about  this  process;  the  explanation  is  simple, 
and  the  means  are  at  hand.  Feeding  a  baby  high  pro¬ 
tein,  by  inducing  putrefactive  changes,  by  calling  forth 
large  amounts  of  alkaline  intestinal  juices,  and  by 
bringing  down  large  amounts  of  calcium  in  connection 
with  the  casein,  produces  constipated,  hard  stools. 
Feeding  large  amounts  of  sugars  by  inducing  fermenta¬ 
tion,  with  the  resulting  formation  of  various  irritating 
acids,  will  lead  to  diarrheal  and  acid  stools.  Dont  for¬ 
get  these  important  factors. 


31 


Just  one  word  about  the 

ENERGY  OF  FOODS 

In  the  science  of  physics  the  term  “calory”  is  used. 
This  is  purely  a  scientific  term,  and  means  the  amount 
of  heat  or  energy  that  is  required  to  raise  1  gram  or  1 
kilogram  of  water  one  degree;  30  grams  are  an  ounce. 
The  old  physicists  investigated  the  energy  content  of 
various  foodstuffs,  and  in  their  investigations  they 
found : 

1  ounce  of  protein  represented  about  120  calories. 

1  ounce  of  carbohydrate  represented  approximately  120  calo¬ 
ries. 

1  ounce  of  fat  represented  approximately  270  calories. 

This  is  pure  physics.  It  was  due  to  the  investiga¬ 
tions  of  the  children’s  specialist,  Heubner,  in  connec¬ 
tion  with  the  physiologist,  Rubner,  that  these  physical 
studies  were  applied  to  infant  feeding.  These  men,  in 
their  experiments,  showed  that  a  normal  baby,  to  thrive 
and  gain,  requires  approximately  45  calories  for  every 
pound  of  his  body  weight.  For  example,  a  baby  weigh¬ 
ing  6  pounds  would  require  about  270  calories.  This 
system  of  feeding,  advocated  by  Heubner,  has  been 
adopted  by  many  children’s  specialists.  We,  of  the 
Middle  West,  do  not  follow  very  rigidly,  but  we  recog¬ 
nize  that  it  is  of  value.  We  believe  that  its  value  is 
chiefly  that  of  a  check  upon  us,  and  when  a  baby  is 
not  gaining,  one  may  run  over  the  mixture,  see  approxi¬ 
mately  how  many  calories  one  is  giving  the  baby,  and 
see  if  the  wants  are  covered.  But  let  me  emphasize 
that  we  do  not  advocate  this  as  a  method  of  feeding; 
simply  a  check  to  be  occasionally  employed  upon  the 
amount  of  food  that  we  are  offering. 

Gentlemen,  our  hour  is  long  since  up.  What  points 
of  this  lengthy  discourse  are  going  to  be  of  value 
in  guiding  you  in  your  feeding  and  treatment  of 
nutritional  disease?  Remember,  first  and  foremost, 
the  great  differences  in  putrefaction  and  fermentation; 
that  any  protein  remaining  unabsorbed  in  the  intestinal 
tract  leads  to  putrefaction  and  alkaline  formation,  with 
resulting  hard,  constipated  stools.  Remember  that  any 
carbohydrate  remaining  unabsorbed  in  the  intestinal 
tract  leads  to  fermentation,  and  acid  formation  with 


32 


diarrhea  and  watery  stools.  Remember  the  fermenta¬ 
tion  of  the  carbohydrate  is  greatly  increased  by  the 
whey  elements  of  the  milk  and  by  any  diseased  or 
weakened  condition  of  the  child’s  intestine.  Remem¬ 
ber,  in  a  general  way,  what  I  told  you  of  the  stool  con¬ 
tent,  and  that  the  fat  in  the  form  of  alkaline  soaps  is 
an  important  factor  in  giving  structure  to  the  stool. 
This  is  fat  in  combination  chiefly  with  calcium  and 
magnesium.  Remember  that  in  the  stools  normally 
no  carbohydrate  is  present  and  that  when  milk  is 
boiled  no  undigested  protein  is  present,  thus  disproving 
in  a  rather  general  way  the  previously  held  idea  of 
indigestibility  of  cow’s  milk  casein.  Remember  the 
functions  of  the  different  elements  of  the  food.  Pro¬ 
tein  and  salts  make  up  the  tissues  of  the  body.  Re¬ 
member  what  we  have  said  about  carbohydrate,  and 
remember  that  carbohydrate  and  salts  seem  to  be  im¬ 
portant  factors  in  pulling  water  into  and  out  of  the 
child’s  tissues. 


LECTURE  III 


MODERN  CONCEPTION  OF  “DISTURBANCES 

OF  NUTRITION” 

Gentlemen,  in  the  last  two  lectures  we  concerned  our¬ 
selves  with  the  subject  of  milk  and  with  the  subject  of 
milk  and  the  baby.  Today  let  us  start  the  most  fasci¬ 
nating  of  all  studies,  the  study  of  the  baby.  We  wish 
to  consider  that  great  bewildering  group  of  ailing,  non¬ 
thriving,  sick  children,  some  with  diarrhea,  some  with 
constipation  described  by  the  various  terms,  atrophy, 
marasmus,  malnutrition,  inanition,  indigestion,  gastro¬ 
enteritis,  ileo-colitis,  cholera-inf  an  turn,  and  dysentery. 
You  gentlemen  have  probably  been  reading  and  study¬ 
ing  the  methods  and  teachings  of  the  Eastern  schools. 
I  do  not  wish  to  discuss  or  criticise  in  any  way  what¬ 
soever  the  methods  of  our  Eastern  friends.  My  pur¬ 
pose  solely  is  to  give  you  also  the  viewpoint  of  the 
Middle  West. 

As  regards  this  great  group  of  disturbances  arising 
chiefly  in  the  artificially  fed  baby,  the  Middle  West  in 
a  general  way  follows  the  European  ideas.  Wishing 
information  from  the  very  source,  many  of  our  younger 
men  have  sought  the  European  clinics,  and  it  is  infor¬ 
mation  thus  obtained  which  I  wish  to  convey  to  you. 
After  you  have  thoroughly  mastered  our  methods,  you 
will  be  in  a  position  to  survey  comprehensively  the 
entire  field  and  to  make  an  intelligent  decision  for 
yourselves. 

A  little  review  of  history  will  be  of  great  aid  to  us 
in  understanding  the  modern  developments.  Let  us 
return  for  a  moment  to  the  autopsy  room  in  Vienna 
some  twenty  or  thirty  years  ago.  Vienna,  as  you  know, 
is  almost  the  home  of  pathology.  Post-mortem  exami¬ 
nation  is  conducted  with  the  same  risrid  care  and  exact¬ 
ness  as  is  clinical  investigation.  Every  patient  who 
dies  in  the  Vienna  hospital  must  come  to  the  post¬ 
mortem  table.  It  is  natural  that  with  such  tremendous 
facilities  the  whole  Vienna  teaching  should  follow 
pathological,  anatomical  lines.  Even  the  clinicians 

3 


34 


made  pathology  the  foundation  of  their  diagnoses,  and 
it  was  only  logical  to  attempt  to  divide  this  great  group 
of  sick  children  into  classes  according  to  the  pathologi¬ 
cal  findings.  In  Vienna  in  those  days  one  could  say 
the  conception  was  as  follows : 


The  sick  ~baby  might  be  affected 


The  well  baby  was  in  a 
group  exclusively  by 
himself. 


with 

a.  Dyspepsia, 

b.  Entero-catarrh, 

c.  Cholera  infantum. 

d.  Follicular  enteritis,  etc. 


This  probably  was  the  consensus  of  opinion  of  the 
great  Vienna  pediatricians  and  pathologists.  To  them 
a  well  baby  was  a  child  to  be  neglected,  not  to  be  con¬ 
sidered  at  all  by  medical  men.  The  well  baby  might 
play  in  his  nursery;  be  of  no  interest  until  he  assumed 
one  of  the  types  of  disease.  These  types  of  disease 
were  described  as  local,  pathological,  anatomical 
changes  in  the  gastro-intestinal  tract.  In  other  words, 
if  the  baby  vomited  he  had  gastritis.  If  he  vomited 
and  had  a  slight  diarrhea  he  had  a  gastro-enteritis.  If 
he  had  a  diarrhea  with  bloody  stools  he  had  ileo-colitis 
or  possibly  follicular  enteritis. 

You  see,  then,  that  such  a  viewpoint  made  a  sharp 
distinction  between  the  well  baby  and  the  sick  baby. 
The  well  baby  was  uninteresting,  but  the  sick  baby  by 
showing  local  changes  in  his  gastro-intestinal  tract  be¬ 
came  very  attractive  and  an  object  of  much  study. 
When  it  came  to  put  this  classification  into  clinical 
practice,  however,  great  difficulties  arose,  and  when 
these  clinical,  pathological  diagnoses  had  been  estab¬ 
lished  autopsy  frequently  failed  to  confirm  them. 
Often  clinical  pictures  changed.  What  was  one  day 
diagnosed  entero-catarrh  became  the  following  day 
cholera  infantum.  Hot  even  in  sharp  pictures,  such  as 
follicular  enteritis,  could  the  ulcerated  intestine  always 
be  demonstrated.  And  in  many  cases  showing  the  se¬ 
verest  clinical  symptomatology,  as,  for  instance,  cholera 
infantum,  post-mortem  examination  not  rarely  showed 
absolutely  no  change  in  the  digestive  tract,  other  than 
perhaps  a  slight  reddening  of  the  mucous  membrane. 

Slowly  the  pathologists  became  discouraged.  Gradu¬ 
ally  did  they  lose  their  interest  in  seeking  a  pathological 


35 


foundation,  and  now  if  one  goes  to  Vienna  and  stands 
in  the  great  autopsy  room,  the  lack  of  interest  shown  in 
the  post-mortem  examination  of  infants  is  impressive. 
While  great  groups  of  men  crowd  around  the  tables 
seeking  knowledge  from  the  carefully,  accurately  con¬ 
ducted  autopsies  upon  adults,  dead  infants  are  abso¬ 
lutely  neglected;  not  even  examined.  When  one  asks 
the  busy  professor  why  such  and  such  a  child  is  not 
autopsied,  one  receives  for  an  answer  a  shrug  of  the 
shoulders,  and  the  reply,  “What  is  the  use?  We  never 
find  anything.”  This  mute  evidence  from  the  anatomy 
room  of  Vienna  speaks  for  the  utter  failure  of  path¬ 
ology  to  provide  a  local  anatomical  basis  as  a  classifi¬ 
cation  for  these  disturbances. 

The  next  attempt  was  made  by  the  great  Vienna 
pediatrician,  Escherich.  Noting  the  failure  of  pathol¬ 
ogy,  he  and  his  assistants  sought  to  find  etiological  fac¬ 
tors  in  bacteria.  They  made  numerous  and  valuable 
researches  with  such  ends  in  view.  But  again  did  the 
search  fail,  for  no  specific  micro-organisms  could  be 
found  to  produce  these  specific  clinical  entities.  When 
I  say  he  failed,  gentlemen,  I  do  not  mean  that  lie  failed. 
His  service  was  of  course  of  tremendous  importance, 
because  negative  evidence  is  as  valuable  to  us  as  posi¬ 
tive  evidence,  and  only  could  we  proceed  after  having 
learned  the  valuelessness  of  bacteriology  as  an  aid  to 
our  classifications.  To  this  we  must  always  be  indebted 
to  Escherich  and  his  assistants. 

The  next  great  step  was  taken  by  that  almost  ro¬ 
mantic  figure  in  pediatrics,  Adelbert  Czerny,  the  bril¬ 
liant  Austrian  clinician,  who  was  called  to  the  chair  of 
children’s  diseases  at  Breslau.  The  great  dreams  of 
this  wonderful  man,  aided  by  his  keen  clinical  obser¬ 
vation,  have  given  the  pediatricians  of  the  world  per¬ 
haps  one  of  the  most  novel  and  at  the  same  time  the 
most  useful  conceptions  that  we  have  yet  received. 
We  must  forever  be  indebted  to  Czerny  for  the  intro¬ 
duction  of  the  new  term,  “Disturbance  of  Nutrition.” 
In  employing  the  term,  “Disturbance  of  Nutrition,”  we 
already  have  a  premonition  of  great  changes  that  are 
going  to  result  in  our  therapy.  Disturbance  of  Nutri¬ 
tion  would  imply  that  the  child  as  a  whole  is  affected, 
rather  than  exclusively  his  gastro-intestinal  tract.  Even 
though  the  trouble  may  have  its  origin  in  the  stomach 


36 


and  intestine,  even  though  the  symptoms  may  be  en¬ 
tirely  those  from  the  stomach  and  intestine,  still  every 
organ  in  the  child’s  body  is  influenced.  What  a  tre¬ 
mendous  thought  is  this,  gentlemen,  to  guide  us  in  our 
therapy!  If  the  child  as  a  whole  is  affected,  we  must 
admit  that  changes  may  take  place  in  his  bones,  in  his 
muscles,  in  his  skin,  in  his  entire  organism ;  and  already 
our  keen  interest  in  the  infant’s  stool  slightly  must 
wane.  Whether  this  viewpoint  is  correct  or  not  is  not 
for  me  to  say,  but  it  has  been  of  great  value  in  enhanc¬ 
ing  our  studies  and  guiding  us  in  new  lines  of  treatment. 

Czerny  was  one  of  the  first  to  doubt  the  indigestibil¬ 
ity  of  cow’s  milk  casein.  With  the  doctrine,  “Protein 
can  do  no  harm,”  the  very  antithesis  of  former  teach¬ 
ing,  his  skeptical  brain  cast  the  pediatrics  world  into 
furor. 

Realizing  the  failures  of  pathology  and  bacteriology 
as  aids  to  us  in  classifying  these  conditions,  he  attacked 
them  from  the  viewpoint  of  etiology  and  gave  to  us  the 
famous  Czerny  classification,  which  is  known  all  over 
the  pediatrics  world,  namely,  the  grouping  of  “Disturb- 
ances  of  Nutrition”  according  to  cause.  Gentlemen,  the 
value  of  Czerny’s  viewpoint  has  been  very  great,  indeed. 

1.  Disturbances  on  the  basis  of  infection.  These  may 
be  of  two  types : 

(a)  From  direct  bacterial  infection  of  the  child,  or 

( b )  From  taking  milk  or  food  spoiled  by  bacterial 
action. 

2.  Disturbances  on  the  basis  of  constitution. 

3.  Disturbances  on  the  basis  of  food.  Of  this  latter 
Czerny  described  two  clean-cut  clinical  entities : 

(a)  The  condition,  which  is  called  “Milk  Injury,” 
namely,  a  rather  pasty,  flabby  child,  not  very  sick,  but 
not  thriving,  whose  mother  brings  him  to  the  physician, 
chiefly  for  the  relief  of  constipation.  Czerny  thought 
that  he  found  the  etiological  factor  of  this  condition  in 
high  fat  feeding ;  and  so,  though  he  gave  to  it  the  name 
“Milk  Injury,”  he  really  meant  to  describe  “Fat  In¬ 
jury.” 

( b )  The  condition  he  called  “Starch  Injury” — a 
little  emaciated,  weak,  undernourished  baby,  who  has 
received  an  exclusively  one-sided  starch  diet. 

Czerny’s  immeasurable  contribution  to  us  in  this 
classification  was  the  introduction  of  food  factors  in  the 


37 


causation  of  a  clinical  picture.  For  the  very  first  time 
we  now  hear  and  think  of  a  sharply  defined,  clearly 
described  disease  being  due  to  nothing  else  other  than 
the  food  that  we  are  feeding  the  baby — perfectly  good, 
wholesome  food,  but  mixed  in  improper  proportions. 
You  see  what  a  tremendous  difference  in  our  viewpoint 
this  makes  as  regards  our  conception  of  the  well  baby. 
What  Czerny  has  done  is  to  impress  upon  us  that  the 
well  baby  is  not  necessarily  well,  but  by  a  little  one¬ 
sided  feeding  can  he  be  brought  right  over  into  the 
group  which  we  formerly  reserved  entirely  for  the  sick 
baby.  Like  this — 


In  this  wonderful  study  Czerny  limited  to  two  the 
clinical  types  which  improper  feeding  could  produce, 
namely,  the  pasty,  constipated  child  resulted  from  fat,* 
and  the  emaciated,  undernourished  one  from  exclusive 
starch.  The  diarrheal  diseases  he  believed  due  to  either 
definite  intestinal  infection  or  to  milk  spoiled  by  bac¬ 
terial  action. 

Contemporaneous  with  Czerny,  Finkelstein  was  mak¬ 
ing  his  wonderful  clinical  studies  in  Berlin.  Perfectly 
independently  these  two  men  worked,  Czerny  seeking 
the  causes  of  diseases  and  Finkelstein  describing  clini¬ 
cal  pictures.  Hot  by  theorizing,  not  by  hypothesis,  but 
by  careful  observation  at  the  bedside,  sitting  with  his 
little  patients  by  the  hour,  studying  them  with  the  care 
of  a  scientist  in  his  laboratory,  did  Finkelstein  arrive 
at  conclusions  which  threw  the  already  perturbed  pedia¬ 
trics  world  into  chaos.  The  opportunities  for  clinical 
investigation  in  Berlin  are  enormous.  Many  great  in¬ 
stitutions  are  erected  for  the  large  number  of  illegiti¬ 
mate  children  that  exist  in  that  city.  In  Finkelstein^ 
institution  over  three  hundred  beds  are  reserved  for 
infants  less  than  two  years  of  age.  The  opportunities 
for  studying  and  investigating  these  infants  are,  of 
course,  much  greater  than  in  private  practice,  or  even 
in  ordinary  hospital  work.  Don’t  think  for  a  moment 
that  these  children  are  harmed ;  they  are  simply  studied 


38 


very  carefully.  Many  great  men  are  in  charge  of  such 
institutions,  many  have  had  the  same  opportunity  of 
Finkelstein;  hut  few  have  had  the  great  clinical  insight 
and  judgment  to  accomplish  what  he  has. 

His  work  was  of  a  purely  clinical  nature.  He  studied 
the  babies’  intestinal  reactions.  He  saw  that  some  of 
these  children  had  bad  diarrheas;  some  had  constipa¬ 
tion.  He  saw  that  some  of  these  children  had  fever, 
some  subnormal  temperature.  In  some  the  pulse  was 


markedly  accelerated ;  in  others  it  was  slow,  feeble,  and 
irregular.  In  some  the  respiration  was  markedly  in¬ 
creased,-  rapid  and  deep ;  in  some  it  was  slow  and  weak. 
In  some  the  urine  was  full  of  sugar,  albumen,  and  casts ; 
in  others  it  was  perfectly  normal. 

Varying  from  the  velvety  pink  of  the  normal  baby, 
to  the  inelastic,  flabby,  mud-colored  tint  of  the  child  in 
disease,  the  skin  seemed  subject  to  infinite  variations 
and  change.  So  was  it  with  the  muscles,  some  being 
normal,  some  rigid,  some  flabby. 


39 


In  one  type  of  child  with  evidence  of  great  cerebral 
involvement,  consciousness  was  markedly  disturbed,  and 
in  another  the  sensorium  was  perfectly  free. 

In  these  clinical  studies  Finkelstein  brought  out  one 
fact  of  tremendous  importance,  the  importance  of  which 
had  been  long  overlooked,  namely,  the  child’s  iveight 


curve.  To  make  a  weight  curve  one  must  weigh  the 
baby  every  few  days,  preferably  every  day,  and  plot  out 
a  curve  upon  a  tabulated  sheet,  or,  just  as  simply,  con¬ 
ceive  it  in  the  mind,  as  one  does  for  temperature,  pulse, 
and  respiration.  In  calling  to  our  attention  weight 
curves  Finkelstein  did  us  an  inestimable  service,  for  he 


40 


showed  that  weight  curves  were  diagnostic  of  definite 
clinical  entities.  He  called  attention  to  the  curve  of  the 
healthy  breast-fed  baby,  gaining  steadily  day  by  day, 
the  gain  each  day  being  like  the  one  of  the  day  pre¬ 
vious.  He  reminded  us  of  the  zig-zag  curve  of  the 
bottle-fed  baby,  and  suggested  that  this  asymmetry 
may  be  due  to  the  irregular  retention  and  excretion  of 
salts.  You  remember  we  told  you  that  cow’s  milk  is 
much  richer  in  mineral  matter  than  is  breast  milk,  and 
that  being  concerned  in  the  retention  of  water  in  the 
baby’s  body,  salts  markedly  influence  the  weight.  He 
showed  us  a  curve  characterized  by  cessation  of  gain. 
He  showed  us  a  curve  characterized  by  gradual  loss. 
He  showed  us  a  curve  characterized  by  acute  severe 
loss.  All  these  curves  represent  periods  of  days.  And, 
lastly,  he  showed  us  the  curve  of  a  chronically  sick  baby, 
sick  for  weeks  or  months. 

From  these  studies  emerge  four  distinct  groups. 
What  I  am  now  going  to  give  you  is  the  famous  Finkel- 
stein  classification,  adopted  almost  all  over  Europe, 
adopted  by  many  of  the  men  of  the  Middle  West.  It 
is  based  purely  upon  clinical  observation;  based  upon 
no  theory  at  all;  has  no  foundation  whatsoever  other 
than  careful  observation  at  the  bedside.  Why  Finkel- 
stein  was  not  satisfied  with  etiology  as  a  means  of  classi¬ 
fication  he  explains  in  his  modest  way  by  saying :  “We 
are  still  in  such  a  maze  that  it  might  perhaps  be  wiser 
as  a  guide  to  us  in  further  study  for  the  present  to  con¬ 
tent  ourselves  with  clinical  pictures.  The  truth  is  al¬ 
ways  to  be  found  at  the  bedside.”  The  classification 
is  as  follows : 

1.  Failure  to  Gain. — Infants  who,  though  not  very 
sick,  are  not  thriving  and  gaining  as  they  should.  They 
usually  have  constipated,  soapy  stools,  and  are  subject 
to  infections. 

_  2.  Dyspepsia. — Here  the  picture  is  that  of  a  mild 
diarrhea.  The  child  is  not  very  sick,  but  is  a  little 
peevish  and  irritable — the  type  which  you  gentlemen 
would  call  a  mild  gastro-enteriti.s  or  a  mild  summer 
complaint. 

3.  Intoxication. — This  is  a  very  sick  child.  Diarrhea 
is  marked;  loss  of  weight  rapid  and  severe.  Conscious¬ 
ness  often  is  disturbed,  and  the  temperature  may  be 
high.  It  is  much  the  same  picture  that  you  gentlemen, 


41 


I  presume,  would  call  a  very  severe  gastro-enteritis  or 
a  cholera  infantum. 

4.  Decomposition. — In  this  condition  the  child  has 
been  chronically  ill  with  feeding  difficulties.  Nothing 
has  agreed  with  him  for  weeks.  He  shows  the  great 
emaciation  and  undernourishment  of  which  the  terms 
atrophy,  malnutrition,  and  marasmus  are  descriptive. 

Not  only  are  we  indebted  to  Finkelstein  for  this  beau¬ 
tiful  new  clinical  classification,  but  we  everlastingly 
owe  him  gratitude  for  the  introduction  of  a  new  food 
factor  into  the  study  of  diseases.  Czerny  introduced 
fat,  and  thought  overfeeding  in  fat  brought  on  milk  in¬ 
jury  with  its  associated  constipation.  Finkelstein  from 
this  same  viewpoint  of  disturbance  studied  sugar,  and 
it  was  his  idea  that  overfeeding  in  sugar  produced 
diarrhea.  You  see  what  a  startlingly  new  conception 
this  was.  When  he  described  to  the  pediatrics  world 
the  severe  picture  of  intoxication,  which  as  I  previously 
said  you  would  call  cholera  infantum,  and  laid  the 
cause  of  this  hitherto  deadly,  often  mysterious  disease 
simply  to  excess  of  sugar  in  the  feeding,  the  in¬ 
terested  profession  was  stunned,  amazed,  and  unbeliev¬ 
ing.  In  rapid  succession  from  all  parts  of  the  world, 
seeking  to  confirm  or  to  disprove  this  view,  volleys  of 
new  investigation  and  experiments  were  started,  and 
although  many  of  the  original  theories  have  been  modi¬ 
fied,  still  the  infinite  value  of  this  fundamental  observa¬ 
tion  is  being  day  by  day  more  and  more  impressed 
upon  us. 

The  third  invaluable  contribution  of  Finkelstein  was 
the  grouping  of  these  four  types  under  the  head  of 
“Disturbances  of  Nutrition.'1’  Following  the  footsteps 
of  Czerny,  when  Finkelstein  studied  diarrheal  diseases 
and  noted  the  changed  pulse  rate,  the  changed  respira¬ 
tion,  the  changed  temperature,  the  disturbed  conscious¬ 
ness,  and,  above  all  things,  the  variable  and  impressive 
weight  reactions,  we  can  readily  imagine  his  reasoning 
as  follows:  “Certainly,  this  disturbance  must  be  one 
involving  more  than  the  digestive  canal.  No  matter 
even  though  the  origin  be  purely  gastro-intestinal,  if 
every  function  of  the  body  is  involved  and  affected  we 
must  think  of  the  child  as  one  in  whom  the  entire  nutri¬ 
tion  is  changed,  and  certainly  such  change  must  have 
great  influence  upon  our  treatment.  Under  no  circum- 


42 


stances  must  we  think  of  the  gastro-intestinal  tract 
alone.’7  This  viewpoint  has  been  of  inestimable  value 
to  us  in  directing  our  lines  of  therapy  away  from  the 
child’s  stools  to  that  of  the  child’s  body.  In  this  re¬ 
spect  you  will  find  a  great  difference  of  opinion  between 
the  Eastern  schools  and  those  of  us  who  follow  Finkel- 
stein.  According  to  our  Eastern  friends,  stool  exami¬ 
nation  is  an  absolute  essential  as  a  guide  to  proper 
treatment.  We  believe  that  the  stools  are  valuable 
symptoms  of  disturbance  of  the  gastro-intestinal  tract; 
but  viewing  our  little  patients  from  the  conception  of 
“disturbance  of  nutrition,”  after  having  noted  the  symp¬ 
tom  of  the  stool,  we  often  neglect  it  entirely,  consider¬ 
ing  it  only  in  its  relation  to  the  entire  clinical  picture. 

According  to  the  viewpoint  of  Finkelstein,  the  group¬ 
ing  of  these  diarrheal  diseases  also  as  “disturbances  of 
nutrition”  must  make  stool  examination  absolutely  in¬ 
cidental  to  the  examination  of  the  entire  baby.  The 
symptom  of  the  stool  sinks  into  insignificance  beside 
the  symptom  of  the  baby  as  a  whole.  The  one  symp¬ 
tom  representing  the  baby  is  the  weight.  The  stool  is  a 
symptom  to  be  considered,  it  is  true,  but  not  to  guide 
us.  The  weight  becomes  our  index  for  treatment. 

Finkelstein  did  not  deny  the  influence  of  constitution, 
as  a  factor,  which  Czerny  had  suggested,  and  did  not 
deny  the  importance  of  infection;  but  he  believed  first 
and  foremost  that  most  of  these  disturbances  were  due 
not  so  much  to  constitution,  not  so  much  to  infection,  as 
they  were  due  to  food;  and  when  we  say  food  we  mean, 
of  course,  perfectly  wholesome,  good,  fresh  cow’s  milk, 
given  to  the  child,  however,  in  improper  mixtures. 
Whether  one  follows  Czerny  or  whether  one  follows 
Finkelstein  is  immaterial.  Both  men  have  done  the 
world  a  service  for  which  generations  to  come  must  he 
everlastingly  grateful.  From  the  point  of  view  of  the 
clinician,  however,  the  Finkelstein  classification  is  per¬ 
haps  more  practical. 

By  a  crude  illustration  one  might  perhaps  make  the 
methods  of  procedure  of  these  two  men  more  clear. 
Suppose  we  lived  two  hundred  years  ago,  when  disease 
was  considered  due  to  evil  spirits,  to  witchcraft,  and  to 
demons.  Suppose  at  that  time  that  some  observer  in 
an  inspired  moment  had  conceived  the  idea  of  bacteria, 


43 


and  to  the  eager  world  exclaimed :  “Some  of  these  con¬ 
ditions  are  ‘infectious  diseases/  and  they  are  three 
types : 

Those  from  Pneumococcus, 

Those  from  Streptococcus,  and 
Those  from  Meningococcus.” 

This  is  what  Czerny  did  some  ten  years  ago  when 
out  of  the  bewildering  maze  of  ailing  infants  he  saw 
“disturbances  of  nutrition/’  and  said  they  could  be 
divided  into  three  groups : 

Those  due  to  Constitution, 

Those  due  to  Infection,  and 
Those  due  to  Food. 

Finkelstein,  on  the  other  hand,  had  he  lived  two  hun¬ 
dred  years  ago  when  the  above  hypothetical  individual 
had  discovered  “infectious  disease/’  would  have  jsaid: 
“I  certainly  agree  with  you  that  there  is  a  great  group 
of  diseases  due  to  infection.  We  know  so  little  about 
them,  however,  that  I  think  we  had  better  stick  to  the 
clinical  pictures  and  later  we  can  worry  about  the 
causes.”  He  then  might  have  described,  for  example: 

Pneumonia, 

Meningitis, 

Septicemia, 

Rheumatism. 

He  would  have  agreed  that  these  pictures  might  each 
one  be  due  to  the  pneumococcus,  streptococcus,  or  men¬ 
ingococcus,  but  would  have  left  the  field  open  for  fur¬ 
ther  additions.  In  the  same  way,  the  Finkelstein 
classification  recognizes  “disturbances  of  nutrition,” 
and  shows  four  clinical  pictures : 

1.  Failure  to  gain. 

2.  Dyspepsia. 

3.  Intoxication. 

4.  ‘Decomposition. 

He  accepts  the  factors  offered  by  Czerny  as  causes, 
that  is,  constitution,  infection,  and  food;  but  the  ad¬ 
vantage  of  this  new  point  is  that  it  leaves  the  field  more 
easily  open  for  further  study. 

Either  classification  is  correct.  It  makes  no  differ¬ 
ence  which  you  follow;  but  from  the  clinical  aspect  the 
Finkelstein  idea  is  perhaps  more  practical,  for  it  com- 


44 


pares  with  our  clinical  classification  of  infectious  dis¬ 
ease.  As  clinicians,  what  we  seek  first  is  a  clinical 
picture.  When  we  go  to  the  bedside  we  do  not  ask 
ourselves,  “Is  this  a  disturbance  due  to  pneumococcus 
or  streptococcus  or  meningococcus  ?”  But  we  do  ask, 
“Is  this  a  pneumonia  or  a  septicemia  or  a  meningitis?” 
And  having  established  that,  then  we  seek  the  etiological 
factors.  The  beauty  about  a  clinical  classification  is 
that  it  i.s  true.  Theories  may  be  altered,  ideas  changed, 
new  explanations  advanced,  but  “in  the  clinic  lies  the 
truth.” 

Having  clean-cut  pictures,  we  are  in  a  better  position 
to  seek  causative  factors.  Just  as  in  septicemia  we 
have  already  learned  that  much  the  same  picture  may 
be  due  to  pneumococcus,  streptococcus,  or  influenza,  so 
in  the  same  way  we  can  amplify  these  clinical  types  of 
Finkelstein.  This  classification  I  do  not  myself  believe 
is  the  last  word.  I  doubt  if  it  will  stay  with  us  per¬ 
manently;  but  it  will  be  of  invaluable  help  to  us  in 
further  study. 

Having  recognized  these  four  clinical  types,  Finkel¬ 
stein  himself  now  began  to  seek  causes;  to  fill  in  the 
subheadings.  Stimulated  by  Czerny’s  description  of 
fat  injury  and  by  his  own  discovery  of  the  diarrheal 
effect  of  sugar,  he  attempted  to  place  all  four  of  these 
clinical  pictures  upon  a  food  basis.  In  a  crude  way 
one  might  say  his  first  idea  was  as  follows : 


Intoxication 


Decomposition. 


Failure  to  gain  was  due  either  to  insufficient  food  or 
to  overfeeding  with  fat.  The  latter  was  the  very  same 
condition  that  Czerny  described  as  “Milk  Injury.” 
Finkelstein’s  term,  however,  for  reasons  which  we  will 
discuss  later,  being  “Disturbed  Balance.”  Continuance 
of  the  overfeeding  with  fat  led  to  the  decomposition 
stage.  Overfeeding  with  sugar  led  to  the  stage  of  dys¬ 
pepsia.  If  the  overfeeding  with  sugar  were  continued  in 
the  stage  of  dyspepsia,  intoxication  resulted.  If  the 


45 


mistake  was  overfeeding  with  fat  in  the  stage  of  dys¬ 
pepsia,  decomposition  resulted. 

This  viewpoint  has  been  greatly  modified.  The  hun¬ 
dreds  of  studies  all  over  the  world,  stimulated  by  this 
novel  idea,  have  brought  great  light.  The  all-import¬ 
ant  result  of  this  first  idea  of  Finkelstein  was  to  bring 
the  well  baby  and  the  sick  baby  closer  together.  The 
well  baby  can  now  no  longer  be  secluded  in  his  nursery, 
independent  of  all  interest,  only  to  come  to  our  notice 
when  he  shows  abnormal  symptoms.  The  well  baby 
may  at  any  moment,  due  to  a  little  improper  feeding, 
enter  the  group  of  sick  babies.  Let  me  impress  upon 
you  gentlemen  that  Finkelstein  did  not  deny  infections 
as  a  factor,  did  not  deny  constitution  as  a  factor;  but 
of  all  things  he  did  impress  upon  us  the  very,  very  great 
importance  of  food,  and  he  attempted  to  show  to  us  that 
many  of  the  clinical  pictures  of  even  the  very  worst 
diarrheas  were  due,  not  to  external  influence,  but  due 
-  to  the  milk  mixtures  which  we  ourselves  were  feeding 
the  baby.  This,  of  course,  has  been  of  absolutely  un¬ 
speakable  importance  to  us  in  guiding  our  therapy  and 
stimulating  us  to  deeper  thought. 

Finkelstein’s  idea  as  to  the  importance  of  food  dur¬ 
ing  recent  years  has  undergone  considerable  revision. 
Continued  studies  from  all  parts  of  the  world  have  in¬ 
troduced  new  and  reemphasized  old  factors  in  the  causa¬ 
tion  of  these  disturbances.  ISTow  we  recognize  many 
influences.  The  most  important  of  these  are  as  follows : 

A.  Food. 

I.  Perfectly  good,  wholesome  food. — Pure,  fresh  cow’s 

milk. 

a.  Overfeeding. — This  overfeeding  may  he  of  two 
types : 

1.  Too  great  quantity. 

2.  A  preponderance  of  one  of  the  elements  of  the 
milk,  too  much  fat,  'or  too  much  sugar.  This  is  the 
group  which  Czerny  and  Finkelstein  have  called  so 
strikingly  to  our  attention. 

b.  Hunger. — This  may  be 

1.  Insufficient  total  quantity,  or 

2.  Insufficiency  of  one  or  more  elements  of  the  milk — 
as  protein  and  salt  deficiency  in  prolonged  use  of  barley 
water  and  gruel. 


46 


II.  Spoiled  milk  and  food. — This  was  the  factor  to 
which  Czerny  laid  such  great  importance  in  diarrheal 
disease,  the  factor  which  Finkelstein  considered  rather 
insignificant  as  compared  to  the  factor  of  sugar  fermen¬ 
tation. 

B.  Underlying,  Weak  Constitution. — This  we  re¬ 
cognize  as  an  influence  of  no  small  importance  in 
predisposing  children  to  disturbances. 

C.  Only  recently  are  we  becoming  impressed  with  the 
great  importance  of  the  milder  infections ,  such  as 
coughs  and  colds,  bronchitis  and  cystitis,  as  predis¬ 
posing  agencies. 

D.  Horsing  is  becoming  more  and  more  important. 
Improper  nursing  may  be  of  two  types: 

(a)  The  failure  of  the  individual  nurse  in  taking 
care  of  her  charge,  allowing  him  to  suffer  from  im¬ 
proper  care  of  the  skin,  from  lack  of  cleanliness,  from 
overclothing  and  overheating. 

(b)  A  weakness  inherent  to  our  hospitals  is  that  of 
the  infant  ward.  Here  one  nurse,  no  matter  how  effi¬ 
cient,  is  in  charge  of  many  babies.  She  cannot  give 
each  child  individual  care.  She  cannot  take  the  proper 
interest  in  the  preparation  and  offering  of  the  babies’ 
bottles.  The  children  suffering  from  lack  of  exercise 
lie  in  their  beds  as  plants  rather  than  as  animals,  each 
day  approaching  a  little  more  closely  the  danger  of  a 
disturbance  of  nutrition. 

One  last  word  a.s  to  diagnosis.  How  are  we  to  diag¬ 
nose  a  nutritional  disturbance?  We  have  two  valua¬ 
ble  aids : 

1.  A  careful  history.  Information  of  frequent  di¬ 
gestive  disturbances,  information  of  frequent  infections, 
improper  care,  a  weak  constitution,  or  backward  devel¬ 
opment,  would  lead  us  to  think  strongly  of  nutritional 
disturbance  as  being  a  factor  in  the  present  complaint. 

2.  Above  all  things,  gentlemen,  never  neglect,  and 
learn  to  know,  the  reactions  to  food  and  to  hunger. 
This  is  the  immeasurable  assistance  which  Finkelstein 
has  offered  us. 

( a )  In  one  child  with  severe  diarrhea  the  addition 
of  a  full  bottle  of  food  is  fatal,  the  child  dying,  with 


47 


the  severest  symptoms  of  intoxication  and  with  a  rapid 
loss  of  weight.  In  this  same  child  the  complete  with¬ 
drawal  of  food  for  twenty-four  hours  seems  to  effect  a 
rapid,  striking  improvement.  It  was,  in  a  way,  this 
so-called  paradoxical  reaction  that  first  led  Finkelstein 
to  the  careful  study  of  food  in  these  diarrheal  condi¬ 
tions.  Addition  of  food  kills,  withdrawal  of  food  saves. 
What  better  clinical  evidence  can  there  be  that  food  is 
of  vital  importance  in  these  processes  ? 

( b )  In  some  children  complete  withdrawal  of  food 
for  twenty-four  hours  leads  to  a  rapid  loss  of  many 
ounces  of  weight,  and  death,  with  all  symptoms  of 
collapse. 

Of  these  clinical  pictures,  of  these  weight  curves,  of 
these  food  reactions,  we  shall  hear  more  in  the  next 
lectures. 

To  conclude,  we  have  learned  this  morning,  gentle¬ 
men,  that  in  the  great  group  of  nonthriving  children, 
the  children  with  diarrhea,  the  children  with  constipa¬ 
tion,  pathological  examination  of  the  intestinal  tract  as 
a  means  of  classification  is  of  little  aid  to  us.  We  have 
learned  that  the  science  of  bacteriology  helps  us  but 
little.  Czerny,  with  a  wonderful  conception  of  the 
“disturbances  of  nutrition/’  takes  our  attention  away 
from  the  intestinal  tract,  makes  us  think  of  the  baby 
as  a  whole,  and  Czerny  does  us  an  infinite  service  by 
doubting  the  danger  of  protein  and  first  calling  our 
attention  to  the  importance  of  food  (of  fat)  in  the  pro¬ 
duction  of  the  clinical  picture  of  nonthriving,  consti¬ 
pated  children.  Finkelstein,  in  a  way  following  the 
footsteps  of  Czerny,  arriving  at  these  conclusions 
through  careful  clinical  observation,  impresses  us  with 
the  importance  of  all  foods  in  causing  these  disturb¬ 
ances,  agreeing  with  Czerny  in  some  respects  as  to  the 
effects  of  fat,  doing  us  immeasurable  good  in  calling 
to  our  attention  the  effects  of  sugar  in  causing  diar¬ 
rheas.  Laying  small'  value  upon  the  factors  of  consti¬ 
tution  and  of  infection  in  the  production  of  these  dis¬ 
eases,  he  believes  disturbances  of  nutrition  to  be  almost 
exclusively  due  to  food — perfectly  good,  wholesome 
milk,  given  in  improper  amounts  and  diluted  in  im¬ 
proper  proportion.  We  can  never  be  sufficiently  grate¬ 
ful  to  him  for  placing  diarrheal  diseases  under  the  term 
“Disturbances  of  Nutrition.” 


48 


This  magnificent  conception  is  of  inestimable  value 
to  us  in  the  treatment  of  our  children.  From  this 
viewpoint  the  stool  becomes  a  symptom,  the  baby  as  a 
whole  becomes  the  important  consideration.  The  stool 
becomes  absolutely  subservient  to  the  whole  clinical 
picture.  Just  think  what  this  means.  This  means  we 
must  never  devote  ourselves  to  the  intestine  alone,  but 
only  the  intestine  in  relation  to  the  whole  body.  In 
our  deeper  interests  in  the  child’s  body  we  may  be 
forced  to  do  what  seems  to  be  worst  for  the  intestinal 
tract.  This  viewpoint  impresses  upon  us  finally,  irre¬ 
vocably,  the  tremendous  importance  of  the  weight  curve. 
The  weight  curve  expresses  the  baby’s  condition  as  a 
whole.  The  stool  is  only  the  expression  of  the  intes¬ 
tinal  tract. 

With  the  conception  of  the  great  importance  of  food, 
the  well  baby  becomes  a  sick  baby.  The  well  baby  can 
be  made  to  assume  any  clinical  type  due  to  variation  in 
his  feeding.  Gentlemen,  if  you  only  will  remember 
this,  if  you  only  will  see  your  well  babies  more  often, 
if  you  only  will  think  of  them  as  sick  babies,  treat 
them  with  the  same  care  and  consideration  that  you 
would  a  patient  with  infectious  disease,  I  can  assure 
you  that  you  will  have  little  trouble  with  the  babies, 
little  trouble  with  the  mothers,  and  the  feeding  cases 
you  get  in  your  practice  will  become  a  pleasure  rather 
than  a  burden. 


LECTURE  IV 


FAILURE  TO  GAIN 

Gentlemen,  you  remember  that  in  our  last  lecture  we 
spoke  of  the  various  viewpoints  given  to  us  by  the  great 
pediatricians.  We  told  you  of  the  failure  of  the  Vienna 
school  to  place  these  diseases  upon  a  definite  pathologi¬ 
cal  anatomical  basis.  We  spoke  of  the  failure  of  Es- 
cherich  to  find  .specific  bacterial  causes.  Don’t  misun¬ 
derstand  me,  gentlemen ;  the  ideas  failed.  The  men 
succeeded.  Patient,  conscientious  perseverance  of  these 
students  cleared  away  the  obstacles  that  would  other¬ 
wise  have  prevented  the  advent  of  the  newer  concep¬ 
tions.  You  remember  it  was  Adelbert  Czerny,  the 
skeptic,  the  keen  observer,  the  deep  philosopher,  who 
gave  to  us  the  newer  thoughts.  You  remember  he  no 
longer  spoke  of  diseases  of  the  gastro-intestinal  tract. 
To  him,  these  disturbances  were  “disturbances  of  nutri¬ 
tion.”  The  baby  was  no  longer  diseased  solely  in  his 
stomach  and  intestines,  but  changes  were  effected  in 
every  sinew  and  fiber  of  the  body.  It  was  Czerny  who, 
for  the  first  time,  cast  doubt  upon  the  old  orthodox  idea 
of  the  indigestibility  of  cow’s  milk  casein.  It  was 
Czerny  who,  for  the  first  time,  called  to  our  attention 
the  factor  of  food  in  the  production  of  definite  clinical 
pictures.  Of  the  food  elements  he  investigated,  fat  and 
starch  were  the  ones  whose  physiological  action  he 
brought  to  our  notice  by  two  clean-cut  clinical  pictures : 
Too  much  fat  was  the  causative  factor  in  nonthriving 
constipated  infants ;  too  much  starch  produced  another 
clinical  entity.  It. was  Czerny  who  gave  to  us  an  etio- 
I  logical  classification.  You  remember  the  classification? 
j  Nutritional  disturbances  were  those 

a.  On  the  basis  of  constitution. 

b.  On  the  basis  of  infection:  these  were  the  diar- 
rheal  diseases.  Two  factors  might  here  be  concerned : 

(1)  True  infection  of  the  gastro-intestinal  tract  with 
germs  of  specific  diseases,  such  as  dysentery  or  cholera, 

or> 

(2)  Poisoning,  resulting  from  the  drinking  of  spoiled 
food — food  which  had  not  been  properly  cared  for  and 

4 

' 


50 


had  become  a  great  culture  medium  for  the  common 
everyday  organisms. 

c.  Disturbances  due  to  food: 

(1)  Milk  injury. 

(2)  Starch  injury. 

So,  if  we  follow  Czerny,  we  no  longer  speak  of  gas¬ 
tritis,  gastro-enteritis,  and  cholera  infantum ;  but  rather 
of  a  disturbance  due  to  constitution,  due  to  infection, 
or  due  to  food. 

In  a  and  b  he  gave  us  etiological  factors;  in  c  he 
gave  us  an  etiological  factor  with  two  beautifully  de¬ 
scribed  clinical  pictures. 

You  remember  that  while  this  epoch-making  work 
was  being  evolved  Finkelstein  in  Berlin  was  making 
his  great  studies  from  a  purely  clinical  viewpoint. 

In  today’s  lecture  I  wish  to  discuss  with  you  Czerny’s 
“Milk  Injury”  and  to  show  how  this  has  been  modified 
by  clinical  observation. 

Czerny’s  description  is  about  as  follows :  A  mother 
brings  her  infant  to  you,  complaining  that  he  is  not 
thriving  and  that  he  is  very  constipated;  she  does  not 
regard  him  as  being  sick — just  wants  a  little  advice. 
You,  doubtless,  have  seen  many  such  cases  in  your 
practice.  Upon  examination  you  will  find  a  rather 
pasty,  not  badly  nourished,  somewhat  anemic-looking 
child.  He  is  a  little  flabby.  You  think  of  a  beginning 
rickets;  you  sit  him  up  upon  the  table  and  he  falls  to¬ 
gether,  showing  a  somewhat  flaccid  musculature.  His 
weight  is  perhaps  slightly  below  normal.  Upon  ques¬ 
tioning  the  mother  as  regards  the  history,  you  learn 
that  he  is  not  gaining  as  well  as  he  used  to ;  that  he  is 
a  little  peevish  and  fretful ;  that  he  vomits  occasionally ; 
that  at  times  he  is  a  little  feverish;  that  he  is  subject 
to  mild  infections ;  and  above  everything  else,  that  the 
mother  dwells  upon  the  constipated,  dry,  crumbly,  soap-  ' 
like  stools,  which  characteristically  do  not  adhere  to  the 
diaper,  but  can  be  easily  brushed  away.  To  the  mother 
the  chief  trouble  is  the  constipation. 

You  think  the  child  is  perhaps  undernourished;  you 
increase  his  diet;  but  he  does  not  gain.  If  anything,  he 
becomes  a  little  more  peevish  and  irritable,  and  the 
constipated  stools  more  persistent. 


51 


In  seeking  the  cause  of  this  condition,  Czerny’s  at¬ 
tention  became  focused  sharply  upon  these  abnormal 
bowel  movements,  and  here  he  made  a  tremendous  dis¬ 
covery.  You  remember  that  in  our  second  lecture  we 
spoke  of  the  way  in  which  fat  normally  leaves  the  in¬ 
testine  ;  that  a  certain  amount  of  it — a  rather  small  per 

I  cent — normally  combines  with  alkalies,  such  as  calcium 

,  and  magnesium,  and  leaves  the  intestine  in  the  form  of 
soap.  To  Czerny’s  great  interest,  the  stools  of  the 
babies  we  have  described  contained  a  much  greater  per¬ 
centage  of  soap  than  do  stools  of  normal  babies.  If 
the  soap  in  a  normal  baby  was  perhaps  20  per  cent  of 
ihe  fat  of  the  stool,  in  these  babies  it  might  be  50  per 
cent.  Czerny’s  reasoning  was  clear  and  simple.  If  a 

I I  soap  consists  normally  of  fats  combined  with  calcium 
or  magnesium,  if  the  stools  in  these  children  consist  of 
an  abnormally  increased  amount  of  soap,  then,  from 
these  children,  there  must  be  an  excessive  excretion  of 
mineral  matter — of  calcium  and  magnesium — and  the 
general  symptoms  might  be  explained  as  a  disturbance 
of  nutrition  in  which  loss  of  mineral  matter  played  a 
prominent  part.  If  the  mineral  matter  combines  with 
fat  to  form  soaps,  then,  by  reducing  the  fat  in  the 

i  baby’s  diet,  we  should  decrease  soap  formation  and  thus 
lessen  mineral  loss ;  by  increasing  fat  in  the  diet,  we 
should  enhance  soap  formation  and  increase  mineral 

:  loss.  True  enough,  Czerny’s  assistants,  by  offering 
these  children  increased  quantities  of  fat,  were  able  to 
increase  soap  formation  and  cause  greater  mineral  ex¬ 
cretion.  The  solution  to  the  question  of  treatment  was 
now  relatively  simple.  All  that  was  necessary  was  to 
!  diminish  the  amount  of  fat  in  the  baby’s  bottle,  substi¬ 
tute  for  this  some  food  of  equal  caloric  value,  and  the 
child  should  thrive.  To  accomplish  this  purpose, 
Czerny  used  a  mixture  known  as  Keller’s  Malt  Soup. 
This  is  made  as  follows : 

a.  Take  one-third  of -a  quart  of  milk,  adding  to  it  1 
ounce  of  ordinary  flour. 

b.  In  another  mixture,  to  two-thirds  of  a  quart  of 
water  add  about  3%  ounces  of  malt  soup  extract.  In 
this  country  this  latter  is  put  up  by  Borcherdt  or  the 
“Maltine”  concern. 

c.  Add  the  two  mixtures  together,  boil,  and  you  have 
a  food  that  is  an  absolute  cure,  a  perfectly  ideal  treat- 


52 


ment  for  this  condition.  The  baby’s  constipation  sub¬ 
sides,  the  stools  become  normal,  be  gains  in  weight,  and 
becomes  brighter  and  happier  in  every  way. 

In  taking  up  this  subject  of  “Milk  Injury”  or  “Fat 
Injury,”  I  hesitated  somewhat.  I  did  not  know  whether 
it  would  be  wise  to  go  into  this  detail,  showing  you  the 
reasoning  of  these  observers,  or  to  state  simply  that 
“The  symptoms  are  so  and  so  the  treatment  so  and  so.” 
Upon  consideration,  however,  I  thought  I  should  like 
to  get  you  to  see  the  fundamental  “why”  at  the  basis 
of  these  observations,  because  if  you  master  the  under¬ 
lying  principles  at  stake,  you  will  have  the  key,  not 
only  to  the  treatment  of  this  particular  condition,  but 
also  to  many  of  the  cases  of  constipation  which  you 
meet  in  your  daily  children’s  practice. 

While  these  brilliant  experiments  in  Breslau  were 
being  conducted,  Finkelstein,  in  his  institution  in  Ber¬ 
lin,  was  attacking  the  problem  from  the  standpoint  of 
careful  study  at  the  bedside,  of  accurate  clinical  obser¬ 
vation.  Perfectly  independently,  he  studied  a  great 
group  of  children,  many  of  whom  were  apparently  not 
very  ill,  all  of  whom  showed  a  “failure  to  gain.”  In 
some,  marked  constipation  was  present;  in  others,  bowel 
movements  were  more  nearly  normal.  In  these  studies 
Finkelstein  and  the  men  influenced  by  his  teaching 
showed  that  there  were  many  factors  featuring  in  the 
etiology : 

(1)  Some  children  showed  the  typical  picture  of 
Czerny’s  “Milk  Injury,”  who,  however,  were  getting  in¬ 
sufficient  food ;  increase  of  diet  brought  about  a  speedy 
cure  with  correction  of  the  intestinal  symptoms.  This, 
you  understand,  strictly  speaking,  does  not  belong  to 
the  group  of  cases  we  are  discussing.  I  place  it  here, 
however,  as  did  Finkelstein,  for,  from  a  clinical  stand¬ 
point,  you  will  meet  with  such  cases  frequently  in  your 
practice.  In  true  “Milk  Injury,”  as  described  by 
Czerny,  increase  in  total  food  volume  does  not  result  in 
gain. 

(2)  Some  children  who  were  recovering  from  ordi¬ 
nary  infections  showed  this  very  same  symptomatology. 
These  children  had  been  thriving  perfectly  until  taken 
ill  with  a  cough  or  a  cold  or  a  mild  cystitis,  and  upon 
recovery,  with  absolutely  no  change  of  diet,  spontane¬ 
ously  developed  this  disturbance.  Here,  then,  fat  alone 


53 


or  even  the  food,  could  not  be  blamed,  for  the  baby 
bad  previously  been  gaining  on  the  very  same  mixture. 

(3)  In  another  group  of  cases,  improper  care  of  the 
baby,  whether  in  the  home  or  in  the  hospital,  in  some 
mysterious  way  seemed  to  predispose  to  this  disturb¬ 
ance.  The  explanation  for  this  is  not  as  yet  clear. 
You  remember  we  are  confining  ourselves,  for  the  pres¬ 
ent,  chiefly  to  clinical  observation. 

(4)  A  very  important  group  of  children,  who  seem 
to  suffer  with  a  weak  constitution,  such  as  congenital 
heart  disease  or  other  hereditary  anomalies,  easily  pro¬ 
gress  to  this  condition. 

(5)  Lastly,  there  was  the  group  in  the  clean-cut,  defi¬ 
nite  form  in  which  too  much  milk,  or,  as  Czerny  would 
have  it,  too  much  fat,  seemed  to  be  the  important  factor. 

Gentlemen,  already  you  see  what  tremendous  influence 
clinical  observation  made  upon  our  ideas  of  this  dis¬ 
ease.  Czerny  gave  to  us  the  wonderful  conception  of 
disturbance  of  nutrition;  then  temporarily  forgot  it,  in 
his  intense  interest  in  the  baby’s  stool,  and  overlooked 
other  factors,  perfectly  independent  of  the  food,  which 
might  have  been  concerned.  Finkelstein  and  his  stu¬ 
dents,  in  adhering  to  the  broader  conception,  the  origin 
nal  idea  of  Czerny,  regarding  the  stool  purely  and 
simply  as  a  symptom  and  not  a  cause,  were  able  to  add 
considerable  to  our  knowledge. 

Let  us  return  for  a  moment  to  the  type  of  case  in 
which  both  Czerny  and  Finkelstein  noted  a  rather  high 
amount  of  fat  in  the  diet.  The  tremendous  number  of 
observations  and  experiments  stimulated  by  Czerny’s 
novel  conception  began  to  bear  fruit,  but,  as  time  pro¬ 
gressed,  these  observations  and  experiments  began  grad¬ 
ually  to  speak  against  the  primary  influence  of  fat. 
First,  it  was  shown  that  in  some  cases,  in  spite  of  the 
high  fat  diet,  in  spite  of  the  soapy,  fatty  stool,  there 
was  no  total  mineral  loss  to  the  body.  True,  the  min¬ 
eral  matter  in  combination  with  the  fat  was  increased, 
but  the  mineral  matter  excreted  in  combinations  as  salts 
was  decreased,  and  so  the  sum  total  was  not  above 
normal. 

A  second  tremendous  argument  against  the  primary 
importance  of  the  fat  were  the  brilliant  metabolic 
studies  of  young  Hans  Barth,  whose  tragic  death  in 
the  present  war  has  been  such  a  sad  blow  to  modern 


54 


pediatrics.  He  and  his  coworkers  showed  that  in  many 
of  these  cases  the  amount  of  total  mineral  matter  lost 
in  the  form  of  calcium  and  magnesium  was  infinitely 
greater  than  could  be  explained  by  the  soap  formation 
in  the  stool. 

And,  lastly,  comes  the  ever  valuable,  unexplainable 
clinical  observation  that  these  children  with  well  devel¬ 
oped,  perfectly  typical  milk  or  fat  injury  can  be  cured 
in  rapid,  striking  fashion  by  the  use  of  breast  milk. 
Breast  milk,  as  you  remember,  contains  the  very  same 
amount  of  fat  as  cow’s  milk.  This  is  an  unanswerable 
argument.  If  a  baby,  showing  the  picture  of  milk 
injury  on  cow’s  milk  feeding,  can  he  cured  at  once  by 
the  use  of  breast  milk,  then  fat  exclusively,  by  itself, 
can  scarcely  be  the  sole  factor  in  the  etiology.  We, 
blindly  groping  for  explanation,  must  conclude  that  fat 
alone  cannot  he  responsible,  but  fat  plus  some  invisible 
mysterious  element  contained  in  cow’s  milk  and  not  in 
breast  milk. 

During  the  furor  accompanying  Czerny’s  discovery 
and  the  battles  waged  by  his  supporters  and  his  critics, 
Freund  was  making  brilliant,  almost  conclusive,  experi¬ 
ments  in  his  own  institution.  He  fed  babies  showing 
the  typical  picture  of  milk  injury  various  foods,  such 
as  starch.  This  had  little  effect  upon  the  stool.  He 
fed  them  sesam  oil,  sugar  of  milk,  and  malt  extract. 
Lo  and  behold !  under  the  influence  of  these  latter  three 
articles  of  diet  the  soaps  disappeared ;  the  fats  were  ex¬ 
creted  in  other  combinations,  and  the  constipation  was 
cured.  This  observation  seemed  uncanny,  full  of  mys¬ 
tery.  What  could  he  the  underlying  principle?  Freund 
explains  it  for  us  in  what  seems  very  beautiful,  simple 
reasoning. 

Gentlemen,  you  remember  in  our  previous  lectures 
we  dwelt  upon  the  processes  of  putrefaction  and  fer¬ 
mentation.  We  spoke  of  the  alkali-forming  protein, 
of  the  rather  nonfermenting  higher  carbohydrates,  and 
the  acid-forming  fermenting  lower  carbohydrates.  The 
substances  which  were  apparently  of  great  influence  in 
correcting  the  constipated  stool  were  those  aiding  fer¬ 
mentation,  those  tending  to  make  the  intestinal  contents 
acid;  and  now  Freund  reminds  us  of  a  little  simple 
chemical  process  which  previously  had  been  overlooked, 
viz.,  that  fat  does  not  readily  form  into  soaps  in  the 


55 


presence  of  acids,  but,  in  a  way,  combines  with  them 
to  form  the  so-called  fatty  acids.  Soaps  in  the  pres¬ 
ence  of  acids  are  completely  split  up  just  as  if  they 
were  salts.  Gentlemen,  do  you  grasp  the  importance 
of  this  contribution  of  Freund?  Think  of  it  carefully 
for  a  moment.  If  this  be  true,  soap  formation  is  a 
result  and  not  a  cause.  Soap  formation  is  simply  a 
symptom  of  the  intestinal  reaction  and  not  a  factor 
in  affecting  it.  Feeding  substances  like  protein,  which 
alkalinize  the  intestine,  favor  soap  formation  and  thus 
constipation.  Feeding  substances  like  carbohydrate, 
which  make  the  intestine  acid,  break  up  the  soap  forma¬ 
tion  and  cause  the  looser  type  of  bowel  movement. 
Gentlemen,  I  urge  upon  you  to  give  this  matter  care¬ 
ful  consideration,  to  hold  the  principle'  before  you  at 
all  times,  because  in  mastering  it  you  have  mastered 
one  of  the  great  causes  of  constipation  in  infants.  “Fat 
in  an  alkaline  intestine  forms  soap ;  in  an  acid  intes¬ 
tine ,  fatty  acid.” 

And  now,  if  this  great  mass  of  careful  observation 
and  scientific  experiment  proves  to  us  that  the  con¬ 
stipated  soapy  stool  is  an  effect  and  not  a  cause,  are 
we  any  closer  to  a  clearer  understanding  of  the  picture 
of  milk  injury?  With  true  American  lack  of  respect 
for  dignity  and  title,  one  day  I  assailed  Finkelstein 
in  a  corner  of  his  great  institution,  from  which  the 
modest  little  man  could  not  escape,  and  asked  him  to 
make  the  matter  clear  to  me.  I  never  left  him  until, 
filled  with  wonder  and  admiration,  I  had  obtained  his 
own  personal  viewpoint.  He  reminded  me  that  in  feed¬ 
ing  a  baby  we  must  consider  the  food ,  the  intestine, 
and  by  all  means  that  factor  which  so  frequently  and 
at  such  tremendous  cost  is  overlooked  by  men  speaking 
exclusively  of  “gastro-intestinal  disease”  rather  than 
“disturbance  of  nutrition” — the  needs  of  the  child’s 
body.  He  reminded  me  that  in  feeding  Keller’s  Malt 
Soup  one  reduces  the  fat,  but,  at  the  same  time,  mark¬ 
edly  increases  the  carbohydrate.  Simple  reasoning, 
simple  skepticism,  forces  the  question,  “How  does  one 
know  that  this  gain,  that  this  recovery,  was  due  to  the 
reduction  of  the  fat?”  Is  it  not  just  as  reasonable  to 
assume  that  the  increase  of  the  carbohydrate  was  a 
factor  of  equal  or  even  greater  importance?  Is  it  not 
likely  that  children  with  weak  constitutions,  children 


56 


recovering  from  infections,  children  suffering  from  neg¬ 
lect,  need  more  carbohydrate,  more  energy,  than  does 
the  normal  baby?  Is  not  the  primary  consideration  in 
these  cases  the  demands  of  the  child's  body  rather  than 
the  condition  of  his  digestive  tract?  Have  you  forgot¬ 
ten  the  striking  statement  of  Naunyn,  “The  fat  burns 
in  the  fire  of  the  carbohydrate  ?”  With  such  a  remark¬ 
able  viewpoint,  the  condition  of  the  digestive  tract 
fades  into  insignificance  before  the  primary  considera¬ 
tion  of  the  child’s  body.  The  child’s  vigor  and  strength 
depend  upon  the  amount  of  carbohydrate  offered,  and 
are  perfectly  independent  of  the  reaction  of  the  intes¬ 
tinal  tract.  Whether  the  fat  in  the  stool  is  excreted 
in  the  form  of  soap  or  whether  it  is  excreted  as  fatty 
acid  depends  upon  the  reaction  of  the  intestinal  con¬ 
tents.  If  the  contents  are  alkaline,  soaps  are  formed; 
if  acid,  fatty  acids  result.  In  Keller’s  Malt  Soup  we 
have  an  ideal  mixture  to  create  an  acid  condition  in 
the  intestine.  Low  protein  from  the  dilution  of  the 
milk  lessens  the  alkali  formation ;  high  carbohydrate 
favors  acid.  Due  to  this  acid,  the  fat  soaps  are  split 
up  and  constipation  corrected;  but  the  great  benefit  to 
the  child — the  gain  in  weight,  the  improved  tone  of  the 
muscles,  the  returning  elasticity  to  the  skin — depends 
not  upon  the  correction  of  the  stool,  but  upon  the  inr 
creased  supply  of  carbohydrate  offered  to  the  needy 
tissues. 

It  was  for  this  reason  that  Finkelstein  introduced 
the  term  “disturbed  balance.”  ITe  meant  to  imply  that 
the  primary  fault  was  not  one  of  fat  injury,  was  not 
one  of  chronic  fat  indigestion,  as  is  the  viewpoint  of 
so  many  men,  but  that  the  trouble  lay  in  a  disturbed 
balance  between  carbohydrate  and  fat,  perhaps  carbo¬ 
hydrate  and  protein,  in  the  diet,  the  body  not  receiving 
enough  carbohydrates  to  satisfy  its  wants,  probably 
not  receiving  enough  carbohydrates  to  successfully  per¬ 
form  the  metabolism  of  the  fat.  This  viewpoint  in  a 
striking  way  makes  clear  to  us  the  brilliant  success 
from  feeding  of  breast  milk.  Breast  milk  offers  the 
body  high  carbohydrate;  breast  milk,  with  its  high  car¬ 
bohydrate  and  low  protein,  establishes  processes  of  fer¬ 
mentation  in  the  intestinal  tract  and  does  away  with 
constipation. 


57 


This  viewpoint,  perhaps,  does  not  explain  every  case ; 
perhaps  some  cases  are  really  due  to  a  primary  fat  in¬ 
digestion;  but,  at  any  rate,  we  learn  much  from  this 
conception,  and  a  great  group  of  cases  become  clear  to 
us.  Probably  in  the  majority  of  cases,  as  shown  by 
the  results  with  breast  milk,  the  fat  is  indeed  only  a 
secondary  factor. 

Gentlemen,  now  you  see  why  I  have  tried  to  go  into 
detail.  If  you  have  followed  me  carefully,  if  you  have 
understood  the  principles  which  I  am  trying  to  make 
clear,  you  have  in  them  the  key  to  very  many  of  the 
cases  of  constipation  with  which  you  meet  in  your  prac¬ 
tice.  You  see  also  how  chemistry,  physiology,  and  clini¬ 
cal  medicine  are  no  longer  separate  sciences,  but  must 
be  united  and  used  by  the  modern  medical  man  to  build 
up  and  fuse  into  a  really  complete  structure. 

The  diagnosis  of  this  condition  is  easy.  In  your 
practice  you  will  have  to  distinguish  it  only  from  chil¬ 
dren  not  getting  enough  food ;  in  these,  an  increase  of 
a  half  ounce  to  an  ounce  in  each  feeding  will  rapidly 
result  in  cure.  In  the  true  case  of  disturbed  balance 
no  improvement  results. 

TREATMENT 

For  the  young  baby  breast  milk,  which  is  always  the 
ideal  food,  is,  if  it  can  be  obtained,  the  best  treatment. 
In  offering  breast  milk,  let  me  warn  you  of  a  little  com¬ 
plication,  simple  in  its  physiology,  ignorance  of  which, 
however,  may  lead  to  unpleasant  results.  To  illustrate: 


At  point  “ A ”  we  have  changed  from  the  mixture  of 
cow’s  milk,  which  the  baby  was  getting,  to  one  of  breast 
milk.  A  loss  of  several  ounces  occurs,  lasting  sev¬ 
eral  days.  What  is  the  explanation?  Can  any  of  you 


58 


grasp  why  a  loss  of  weight  should  result  from  the  feed¬ 
ing  of  breast  milk?  The  answer  is  to  be  found  in  the 
simplest  physiology.  In  our  first  lecture  we  told  you 
that  cow’s  milk  was  much  richer  in  mineral  matter  than 
is  breast  milk.  In  our  second  lecture  we  told  you  that 
minerals,  particularly  sodium,  were  important  in  bind¬ 
ing  water  to  the  tissues.  If  our  baby  had  been  getting 
a  mixture  of  three-quarters  of  a  quart  of  cow’s  milk, 
he  would  be  getting  5.7  grams  of  salt — over  a  tea¬ 
spoon.  The-  change  to  three-quarters  of  a  quart  of 
breast  milk  reduces  his  salt  intake  to  l1/*?  grams.  You 
see  what  a  great  reduction  there  is  in  the  mineral 
matter  of  his  diet.  For  this  reason,  until  he  gets  prop¬ 
erly  adjusted,  a  water  loss  occurs  from  his  body,  thus 
explaining  the  drop  of  several  ounces  in  the  weight 
curve.  This  loss  is  not  due  to  poor  breast  milk,  is  not 
due  to  insufficient  breast  milk,  but  to  perfectly  normal 
breast  milk,  and  a  knowledge  of  the  very  simple  ex¬ 
planation  will  save  the  mother,  the  wet  nurse,  and  inci¬ 
dentally  you,  much  worry. 

If  artificial  feeding  is  to  be  employed,  what  shall  be 
our  procedure?  Do  we  need  Keller’s  Malt  Soup?  FTo; 
but  we  do  need  the  principles  upon  which  it  is  based. 
We  wish  to  offer  more  carbohydrate  to  the  baby’s  tis¬ 
sues  ;  we  wish  and  must  do  this  without  injuring  the 
intestinal  tract.  In  our  next  lecture  we  shall  learn  that 
mixtures  of  high  carbohydrate  in  connection  with  high 
fat,  particularly  in  connection  with  concentrated  whey 
of  cow’s  milk,  are  dangerous  from  the  intestinal  view¬ 
point.  We,  therefore,  dilute  our  milk,  not  with  the  idea 
of  diluting  the  fat  exclusively,  but  of  simply  making 
up  a  mixture  which  will  enable  us  to  offer  to  the  tissues 
higher  carbohydrate  without  causing  intestinal  compli¬ 
cations.  We  dilute  it  to  one-third,  adding  two-thirds 
water,  and  then  gradually  increase  carbohydrate  until 
we  get  the  improvement  of  the  general  condition  and 
the  more  normal  condition  of  the  stool.  Ordinary  cane 
sugar  is  the  simplest  and  cheapest  carbohydrate  to  use. 
One  word  of  warning,  however,  in  employing  it.  It 
may  become  necessary  to  add  more  than  six  or  eight 
teaspoons  to  a  quart  of  the  mixture  in  order  to  get  the 
physiological  results.  Under  such  circumstances  the 
mother  and  babe  rebel  at  the  sweet  taste;  therefore,  if 
it  becomes  necessary  to  increase  over  six  to  eight  tea- 


59 


spoons,  it  would  be  wise  to  add  some  easily  fermentable 
carbohydrate  less  sweet  to  the  taste.  This  can  be  done 
in  the  form  of  the  above  said  malt  soup  extract.  Don’t 
make  the  mistake,  however,  of  ordering  pure  malt  ex¬ 
tract.  This  does  not  mix  so  readily  with  the  milk,  and 
you  may  get  into  difficulties  with  the  mother;  but  show 
your  superior  knowledge  by  impressing  upon  her  the 
necessity  of  getting  Malt  Soup  Extract.  Several  con¬ 
cerns  put  up  the  malt  extract  in  this  convenient  form. 

In  children  over  two  or  three  months  of  age,  remem¬ 
ber  that  one-third  milk  is  not  sufficient  to  provide  for 
continued  growth.  After  a  short  time  one  must  cau¬ 
tiously  increase  the  concentration  of  the  milk.  The 
increased  protein  may  temporarily  cause  an  alkaline 
action  to  the  intestine  with  a  renewal  of  the  soap  for¬ 
mation  and  constipation.  That  can  readily  be  com¬ 
bated  by  additional  increase  of  carbohydrate. 

One  point  in  the  treatment,  let  me  impress  upon  you, 
what  you  should  not  do.  How  that  you  understand  the 
principles  upon  which  this  condition  is  based  and  upon 
which  we  should  direct  our  treatment,  you  see  how 
utterly  unreasonable,  how  absolutely  without  scruple, 
is  the  physician  who  drugs  these  patients,  treating  their 
constipation  with  calomel,  castor  oil,  and  other  cathar¬ 
tics.  At  our  hospital  at  home,  Dr.  Abt  and  his  associ¬ 
ate,  Dr.  Jampolis,  some  years  ago  made  interesting 
observations  on  perfectly  normal  babies.  Feeding  a 
fine  healthy  baby  a  therapeutic  dose  of  these  drugs 
caused  the  appearance  of  blood  in  the  stool — not  in 
large  quantities,  but  easily  detected  chemically.  Just 
think  of  that,  gentlemen :  feeding  a  perfectly  healthy, 
normal  infant  medicinal  doses  of  calomel  produces  such 
irritation  of  the  iptestine  as  to  make  blood  appear  in 
the  stool.  What  a  crime  is  it,  then,  to  offer  a  little 
child  suffering  from  a  condition  of  disturbed  balance, 
these  strong  intestinal  irritants,  to  try  to  overcome  con¬ 
stipation,  not  by  reason  and  principle,  but  by  brute 
force !  What  this  baby  needs  is  not  medicine ;  he  needs 
sugar. 

Gentlemen,  we  are  now  temporarily  going  to  leave 
Czerny.  Kemember  his  great  service  to  us,  his  service 
in  giving  to  us  the  conception  of  disturbances  of  nutri¬ 
tion;  his  service  to  us  in  casting  doubt  upon  the  in¬ 
digestibility  of  protein ;  his  service  to  us  in  recognizing 


60 


food  as  an  important  factor  in  nutritional  disease. 
W  hat  have  we  learned  from  this  lengthy,  perhaps  com¬ 
plicated  discussion?  We  have  learned  to  think.  Only 
the  light  shed  by  time,  by  distance,  by  laboratory  ex¬ 
periments  stimulated  by  the  keenest  clinical  observa¬ 
tions,  could  make  us  change  allegiance  to  Czerny’s  first 
idea.  Every  great  pediatrician  wTho  was  able  to  read 
these  writings  and  to  comprehend  them  was  influenced. 
The  very  foundation  of  pediatrics  was  moved.  Now, 
from  across  the  space  separating  us  bv  years  from 
Czerny’s  first  work  we  ask  ourselves,  “Did  we  not  all 
err  alike?  Did  we  not  all  make  the  same  fundamental 
error?”  We  were  stirred  by  the  brilliant  conception  of 
disturbance  of  nutrition;  we  temporarily  lost  sight  of 
this  in  our  keen  interest  in  one  symptom — the  stool. 
In  focusing  our  attention  upon  the  stool  we  lost  all 
sense  of  proportions  in  the  discovery  of  the  soap.  In 
this  maze  of  thought,  we  lost  sight  of  the  relation  of 
fat  to  the  other  elements  in  the  milk;  we  lost  sight  of 
the  fact  that  fat  in  an  acid  intestine  makes  fatty  acids; 
in  an  alkaline  intestine  makes  soaps.  Not  that  our 
observations  were  without  value  or  interest ;  much  good 
has  resulted;  but  they  were  in  entire  disproportion  to 
the  great  clinical  picture.  Only  careful,  frequently  re¬ 
peated,  accurate,  bedside  study  resulted  in  putting  us 
again  upon  the  right  path.  Just  as  we  had  forgotten 
to  note  the  relation  of  the  fat  to  the  other  elements  of 
the  milk,  so  had  we  forgotten  to  note  the  relation  of 
the  symptom — the  constipated  stool — to  the  main  clini¬ 
cal  picture.  Just  as  our  exclusive  attention  to  the  fat 
had  led  us  astray,  so  did  our  exclusive  attention  to  the 
stool  divert  us  from  our  original  broad  conception  of 
disturbance  of  nutrition.  Gentlemen,  what  have  we 
learned?  We  have  learned  that  if  we  wish  to  err  only 
slightly,  if  we  wish  to  have  an  anchor  that  will  hold  us 
secure,  let  us  never  forget  that  first,  foremost,  above 
everything  else,  the  fundamental  truth  is  to  be  found 
in  careful,  conscientious  clinical  observation  and  study. 

What  is  the  practical  significance  of  this  lengthy  dis¬ 
course?  If  a  constipated  baby  is  not  gaining  upon  a 
well  regulated  diet,  carefully  increase  it.  If  he  still 
does  not  gain,  make  up  a  mixture  with  a  higher  per  cent 
of  fermentable  carbohydrate  than  was  contained  in  the 
original  formula,  and  increase  gradually  this  carbohy¬ 
drate  until  improvement  occurs. 


LECTURE  V 


THE  STATES  OF  DYSPEPSIA  AND 
INTOXICATION 

Gentlemen,  if  our  last  lecture  was  important  from 
a  standpoint  of  therapy,  today’s  lecture  is  vital,  for 
it  concerns  life.  You  remember  we  spoke  at  our  last 
meeting  of  Czerny’s  new  viewpoint,  “disturbance  of  nu¬ 
trition.”  We  showed  you  bow  he  bad  introduced  food 
as  a  factor  in  causing  disease  and  bow  he  bad  laid  par¬ 
ticular  importance  upon  the  fat.  He  doubted  the  in¬ 
digestibility  of  protein ;  be  gave  us  an  etiological  classi¬ 
fication  ;  and  due  to  this  etiological  classification,  to  bis 
concentration,  perhaps,  on  one  causative  factor,  we 
became  side-tracked  and  focused  too  carefully  upon 
one  symptom — the  stool.  Finkelstein,  you  remember, 
accepted  the  new  viewpoint  of  “disturbance  of  nutri¬ 
tion,”  agreed  that  infection  and  constitution  were  fac¬ 
tors,  but  greatly  enlarged  upon  the  importance  of 
food.  To  him,  most  of  these  disturbances,  including 
even  the  diarrheas,  were  due  not  to  infections,  but 
practically  entirely  to  food  alone.  Clinical  pictures  to 
be  brought  about  by  improper  feeding  were  four: 

The  picture  of  milk  injury  be  saw,  just  as  did 
Czerny,  but  for  reasons*,  which  we  stated  in  the  last 
lecture,  he  changed  the  name  to  Disturbed  Balance. 
The  tremendous  contribution  of  Finkelstein,  in  the 
realm  of  these  food  disturbances,  was  the  placing  of 
diarrheal  cases  within  this  group.  To  him  the  great 
majority  of  diarrheas  met  do  not  belong  to  the  infec¬ 
tious  group  of  Czerny;  do  not  belong  either  to  ( a )  the 
group  caused  by  specific  bacterial  infection  of  the  intes¬ 
tine,  or  to  (b)  those  resulting  from  milk  spoiled  by  bac¬ 
terial  growth,  but  do  belong  to  the  group  of  disturbances 
arising  from  feeding  of  good,  wholesome  pure  milk 
made  into  improper  mixtures. 

The.  history  of  the  observation  and  development  of 
this  food  basis  for  diarrhea  is  fascinating.  The  very 
first  stimulus  to  the  study  came  to  Finkelstein  and  his 
assistants  with  the  appearance  in  their  great  institu¬ 
tion  of  a  number  of  cases  of  severe  diarrbea-gastro-en- 


62 


teritis  as  they  might  then  have  been  called,  or  dis¬ 
turbances  of  nutrition  on  the  basis  of  infection,  as 
Czerny  would  have  said.  Perhaps  it  was  in  a  way 
Czerny’s  conception  of  food  disturbances^  that  led 
these  men  to  investigate  carefully  conditions  in  their 
diet  kitchen.  To  their  interest  and  amazement,  they 
discovered  that  by  an  error  many  of  the  mixtures  were 
being  made  with  unusually  high  quantities  of  sugar. 
Could  the  sugar  be  a  causative  factor  ? 

Pull  of  curiosity  at  this  thought,  they  fed  babies 
large  quantities  of  sugar,  produced  severe  diarrheal 
disease,  and  gave  to  the  pediatrics  world  one  of  the 
most  wonderful  contributions  it  has  yet  received.  Not 
only  could  high  fat  and  low  sugar  produce  a  condition 
of  disturbed  balance,  hut  high  sugar,  on  the  other  hand, 
could  produce  the  severest  diarrheal  disease.  For  the 
moment  we  see  Finkelstein  following  the  same  error  of 
Czerny,  focusing  too  carefully  upon  the  stool,  upon  one 
symptom,  forgetting  the  big  clinical  picture  and  laying 
the  blame  for  almost  every  case  of  had  diarrhea  upon 
too  high  carbohyrdate  in  the  food.  Not  long,  how¬ 
ever,  before  he  saw  his  error. 

The  same  tremendous  objection  applied  to  this  view 
as  did  to  the  original  idea  of  Czerny.  Breast  milk,  the 
ideal  food,  contains  a  large  quantity  of  carbohydrate — 
easily  fermentable  carbohydrate — hut  children,  when 
fed  breast  milk,  do  not  get  these  deadly  diarrheal  dis¬ 
eases.  There  must  he  some  other  important  factor  in 
cow’s  milk — another  mysterious  influence.  This  is 
simple  reasoning,  simple  common  sense.  Careful  clin¬ 
ical  study  again  guides  us  along  the  right  path. 

At  this  time  Ludwig  F.  Meyer,  Finkelstein’s  first 
assistant,  made  a  very  important  clinical  contribution. 
While  his  experiments  are  open  to  all  sorts  of  criti¬ 
cism,  while  in  the  light  of  our  present  knowledge,  they 
can  he  attacked  from  all  sides,  nevertheless,  in  their 
day  they  served  their  purpose.  He  took  cow’s  milk 
and  breast  milk,  separated  them  each  into  curd  and 


whey,  as  for  example : 

Breast  Milk 

Case  in 

-•Whey 

Cow *6  Milk 

Casein^ 

^Whey 

63 


and  after  having  divided  these  mixtures,  he  criss¬ 
crossed,  adding  the  whey  of  cow’s  milk  to  the  casein  of 
breast  milk,  and  the  whey  of  breast  milk  to  the  casein  of 
cow’s  milk.  Feeding  these  mixtures  to  children  sick 
with  diarrheal  diseases  resulted  in  sharp  differences. 
Those  children  getting  the  mixture  containing  the  whey 
of  breast  milk  made  good  recoveries;  those  children 
getting  the  mixture  containing  the  whey  of  cow’s  milk 
did  not  do  so  well. 

Gentlemen,  although  this  experiment  is  open  to 
much  criticism,  it  nevertheless  served  its  important 
purpose.  It  called  to  our  attention  for  the  very  first 
time  the  whey  of  cow’s  milk.  ISTow,  we  hear  of  the 
whey  of  cow’s  milk  as  a  factor  in  producing  disturb¬ 
ance.  We  have  heard  of  protein,  fat,  carbohydrate, 
and  now  we  hear  of  whey ;  and,  after  all  is  it  not 
strange  that  for  so  many  years  we  have  neglected  this 
portion  of  the  milk?  Is  it  not  likely  that  wbey,  with 
almost  four  times  the  salt  content  of  breast  milk,  also 
could  exert  harmful  influences  upon  the  intestine,  per¬ 
haps  due  to  osmotic  conditions  or  to  who  knows  what? 
To  Ludwig  F.  Meyer,  then,  we  are  indebted  for  bring¬ 
ing  to  our  attention  the  whey. 

While  these  observations  were  going  on,  clinical  study 
was  again  bringing  Finkelstein  toward  the  ultimate 
truth.  Increasing  carbohydrate  in  some  milk  mixtures 
resulted  in  diarrhea.  Increasing  carbohydrate  in  oth¬ 
ers,  to  his  mytisfication,  had  no  such  effect.  What 
could  be  the  explanation?  The  solution  was  discovered 
in  the  combining  of  the  above  two  clinical  experiments. 
When  carbohydrate  is  added  to  mixtures  of  cow’s  milk 
rich  in  the  whey  elements,  diarrhea  results ;  when  car¬ 
bohydrate  is  added  to  mixtures  of  cow’s  milk  poor  in 
the  elements  of  the  whey,  no  diarrhea  results.  The 
more  concentrated  the  whey  the  worse  the  diarrhea  ! 
Thus,  you  see,  addi-ng  carbohydrate  to  buttermilk  or  to 
skimmed  milk  will  make  a  laxative  mixture — these  mix¬ 
tures  containing  all  the  whey  elements  of  the  milk. 
Adding  carbohydrate  to  pure  whey  would  cause  a  very 
intense  diarrhea.  I  should  certainly  advise  you  not  to 
try  this.  What  there  is  in  the  whey  that  causes  these 
symptoms  I  do  not  know.  Perhaps  it  is  the  high  salt; 
maybe  the  soluble  albumins;  as  I  have  said  so  fre- 


64 


quently,  “This  is  clinical  observation.’7  Explanations 
will  come  later. 

It  is  human,  however,  to  wish  things  clear,  to  have 
a  picture  to  hold  before  us,  a  guide  for  our  thoughts. 
I  can  offer  you  the  picture  that  has  been  devised  by 
our  great  teachers.  Do  not  take  this  as  an  absolute 
truth,  but  simply  as  an  illustration  pointing  out  the 
processes  of  modern  reasoning.  How  can  a  mixture  of 
whey  and  carbohydrate  produce  these  results? 

formally,  billions  and  billions  of  bacteria  live  in 
the  large  intestine.  The  small  intestine  is  relatively 
sterile.  Only  at  times  wheen  food  is  being  digested 
are  bacteria  found  in  any  amount  in  the  upper  tract. 
With  the  disappearance  of  food,  with  its  absorption 
through  the  intestinal  wall,  the  bacteria  rapidly  go 
back  to  their  home — to  their  normal  environs  in  the 
large  intestine.  Those  left  in  the  upper  tract  are 
killed  probably  by  the  intestinal  cells  and  by  the  diges¬ 
tive  juices. 

Post-mortem  examination  in  many  cases  of  severe 
diarrhea,  however,  reveals  the  very  interesting  fact 
that  the  upper  intestine  is  swarming  with  micro-organ¬ 
isms — not  abnormal  ones  but  simply  those  which  live 
normally  only  in  the  lower  bowel.  Gentlemen,  what  has 
now  happened?  Normally  the  upper  intestine  is  able 
to  keep  its  contents  sterile,  perhaps  through  the  bac¬ 
tericidal  quality  of  the  digestive  juices,  perhaps 
through  the  properties  of  the  living  epithelial  cells. 
Something  must  have  impaired  this  function.  Is  it 
not  possible  that  the  digestive  juices  and  the  activities 
of  the  epithelial  cells  have  been  handicapped  by  the 
high  salt  content,  perhaps  by  the  changed  salt  rela¬ 
tions  of  the  cow’s  milk  whey?  Moro’s  experiments 
in  a  way  would  tend  to  confirm  this  hypothesis.  In 
carefully  conducted  researches  he  and  his  assistants 
showed  that  the  intestinal  cells  are  much  more  efficient 
when  active  in  a  medium  of  breast  milk  whey  than  of 
cow’s  milk  whey. 

Once  injured,  these  intestinal  cells  cannot  suppress 
bacterial  growth  in  the  upper  intestine.  The  bacteria 
will  thrive  and  prosper,  and  now,  when  carbohydrate 
is  introduced,  before  the  intestinal  digestive  enzymes 
can  alter  it,  prepare  it  for  assimilation,  and  carry  it 
through  the  intestinal  wall,  the  hungering  bacteria  have 


65 


seized  it,  fermented  it,  and  changed  it  to  the  irritating 
lower  fatty  acids,  such  as  acetic,  butyric,  and  formic. 
Gentlemen,  do  you  remember  that  in  the  first  lecture 
and  in  the  second,  also),  we  tried  to  impress  upon  you 
that  when  bacteria  attack  carbohydrate  the  process  is 
known  as  fermentation,  and  acid  results?  Now,  you 
understand  why.  This  very  same  process  proceeds 
rapidly,  unmolested  by  the  injured  intestinal  epithelium, 
and  a  tremendous  quantity  of  irritating  products  result, 
causing  a  severe  acid,  watery  diarrhea.  Such  is  what 
we  reasonably  may  believe.  Clincial  observation  has 
painted  a  picture  in  abnormal  physiology. 

To  return  to  the  bedside.  Diarrheas  are  of  two  types: 
(a)  A  rather  mild  attack,  with  symptoms  described 
usually  as  mild  gastro-enteritis  or  mild  summer  com¬ 
plaint.  (b)  A  very  intense  attack,  often  deadly  in  na¬ 
ture,  described  as  very  severe  gastro-enteritis,  very 
severe  ileocolitis,  or,  maybe,  cholera  infantum. 

The  first  of  these  conditions  Finkelstein  called  dys¬ 
pepsia;  the  second,  he  called  intoxication,  not  because 
he  had  isolated  any  toxin,  but  because  from  a  clinical 
point  of  view  the  little  patient  appeared  poisoned.  This, 
you  remember,  is  a  clinical  classification,  and  a  clinical 
classification  has  many  advantages.  The  picture  is 
constantly  before  us.  Explanations  will  be  varied, 
causes  amplified,  new  factors  discovered;  but  the  clin¬ 
ical  picture  will  be  unchanged. 

DYSPEPSIA 

This  is  one  of  the  most  frequent  ailments  you  meet. 
The  mother  brings  the  babe  mainly  for  relief  of  intes¬ 
tinal  symptoms.  The  child  has  a  mild  diarrhea — five, 
six  or  eight  watery,  green,  rather  sour-smelling  stools 
with  a  little  mucus;  is  occasionally  vomiting,  and  has 
some  colic. 

Careful  history  shows  nothing  of  importance,  other 
than  perhaps  a  slight  cold.  The  baby’s  sleep  is  dis¬ 
turbed  and  for  a  few  days  he  has  not  been  gaining. 

The  examination  shows  a  baby  not  very  sick — often 
slightly  undernourished,  pale  and  restless,  perhaps  a 
little  peevish  and  irritable.  Consciousness  is  certainly 
not  disturbed ;  there  may  be  shadows  under  the  eyes 
and  the  abdomen  slightly  distended.  Temperature, 

S 

* 


66 


pulse,  and  respiration,  other  than  possibly  a  slight  fever, 
reveal  no  important  change. 

Gentlemen,  we  have  spoken  to  you  about  the  reactions 
to  food  and  to  hunger.  Addition  of  food  or  increase 
of  diet  to  this  patient  will  have  little  effect.  His 
diarrhea  may  become  slightly  worse,  his  general  symp¬ 
toms  a  little  increased ;  but  he  will  show  no  radical 
change.  Withdrawal  of  food — absolute  hunger — 
causes  a  marked  improvement.  Diarrhea  ceases  and 
the  child  becomes  better,  brighter,  and  happier.  There 
may  be  a  moderate  loss  of  a  few  ounces  of  weight  for  a 
day  or  so,  but  then  the  curve  rapidly  swings  to  normal. 

If  we  study  such  a  child  from  a  standpoint  of 
metabolism,  if  we  analyze  carefully  the  amount  of  food 
taken  in  twenty-four  hours,  the  amount  of  matter  ex¬ 
creted  in  the  urine  and  the  stool  for  twenty-four  hours, 
we  find  the  following  changes : 

a .  The  protein  excretion  is  slightly  increased. 

b.  The  fat  is  not  changed  greatly  unless  the  child 
has  been  receiving  some  quantity  in  its  bottle.  In  such 
cases  a  considerable  quantity  of  fat  is  found  in  the 
stools. 

c.  Starch  may  he  found  in  the  stool,  particularly  if 
the  baby  has  been  receiving  a  starchy  diet. 

d.  There  may  he  at  times  a  slight  loss  of  mineral 
matter,  chiefly  of  sodium  and  potassium. 

e.  Above  all  things  are  found  increased  quantities 
of  the  irritating  volatile  lower  fatty  acids,  such  as 
acetic,  butyric,  and  formic. 

Where  do  these  irritating  acids  come  from?  Czerny 
would  have  said  that  they  come  from  bacterial  infection 
of  the  milk  outside  of  the  body;  Finkelstein,  that  these 
acids  are  produced  by  the  normal  bacteria  of  the  in¬ 
testine,  attacking  the  carbohydrates  of  the  milk  under 
the  accelerating  influence  of  the  whey.  The  splendid 
studies  of  the  younger  men,  such  as  Barth,  Edelstein, 
and  others,  stimulated  by  these  controversies,  have 
shown  that  acid  formation  in  the  stool  is  infinitely 
greater  than  the  acid  formation  in  spoiled  milk.  Thus 
must  they  be  created  in  the  body. 

Just  as  clinical  study  enlarged  Czerny’s  idea  of  fat 
injury,  so  did  clinical  study  enlarge  Finkelstein’s  idea 
of  whey-sugar  injury.  Hew  points  added  as  etiological 
factors  are : 


67 


I.  From  the  Standpoint  of  Food. 

a.  As  regards  good,  wholesome,  pure  milk,  the  factor 
upon  whicJi  Finkelstein  has  laid  so  great  stress : 

(1)  Simple  overfeeding  is  a  frequent  cause. 

(2)  Particularly  is  overfeeding  with  sugar- whey 
mixtures  a  tremendous  factor.  This  was  Finkelstein’s 
first  great  contribution. 

(3)  High  sugar  plus  high  fat,  particularly  in  a  me¬ 
dium  of  cow’s  milk  whey,  causes  these  diarrheas.  Many 
men  lay  primary  emphasis  upon  the  fat  in  these  cases, 
for  the  stools  show  great  quantities  of  undigested  fat. 
We  do  not  wish  to  be  dogmatic.  Undoubtedly,  high 
fat,  particularly  if  not  properly  digested,  can  produce 
irritating  products  and  diarrhea.  We  believe,  how¬ 
ever,  the  more  important  process  is  the  primary  fer¬ 
mentation  of  the  carbohydrate,  which  whisks  the  fat 
out  in  the  resulting  diarrhea,  the  fat  appearing  in  the 
stool  as  a  neutral  secondary  element.  We  believe  that 
probably  the  fat  suffers  secondarily  as  the  acids  from 
sugar  fermentation  interfere  with  the  digestive 
enzymes.  The  latter  you  know  work  best  in  an  alka¬ 
line  meduim. 

(b)  As  Regards  Spoiled  Food.  From  the  view¬ 
point  of  Czerny,  spoiled  milk  undoubtedly  at  times  pro¬ 
vides  irritants  to  the  intestine  sufficient  to  cause  these 
symptoms.  Particularly  in  older  children,  during  the 
summer  months,  are  spoiled  foods  of  all  sorts  important 
agents. 

II.  We  have  learned  that  constitution  is  a  factor. 
The  weaker  the  baby  the  more  is  he  predisposed. 

III.  Frequently  repeated  mild  infections,  as  coughs 
and  colds,  are  of  extreme  importance. 

IV.  Heat  and  improper  nursing  must  meet  with  our 
consideration,  and  of  course  many  other  new  influences 
will  he  described.  Probably  all  of  these  in  some  way  or 
another  increase  fermentation  in  the  intestines. 

From  this  viewpoint,  you  can  see  how  relatively  un¬ 
important  is  examination  of  the  stool;  I  mean,  rela¬ 
tively  unimportant  as  a  strict  indication  for  therapy. 
In  any  of  these  dyspeptic  stools,  had  the  baby  been  fed 
starch,  the  starch  granules  would  have  been  whisked 
through  by  the  increased  peristalsis;  had  he  received 
high  fat,  the  fat  would  have  appeared  in  large  quan- 


68 


titles.  Had  we  focused  our  attention  exclusively  upon 
tlie  stool,  forgetting  the  more  general  considerations,  we 
would  have  said,  “This  is  a  disturbance  due  to  starch; 
this  is  a  disturbance  due  to  fat” ;  but  now,  as  Ludwig 
F.  Meyer  once  said  to  me,  in  his  pointed  way,  “When 
you  find  high  fat  in  the  stool,  seek  the  carbohydrate.” 

TREATMENT 

The  treatment  based  upon  these  opinions  must  be 
self-evident  and  simple — just  plain  reason.  If  the  whey 
is  a  factor  injuring  the  intestine  and  permitting  bac¬ 
teria  to  flourish  in  the  upper  digestive  tract,  we  must 
dilute  it.  If  carbohydrate  ferments,  we  must  give  it 
in  a  nonfermentable  form.  The  more  we  dilute  our 
whey,  the  more  we  reduce  this  factor  injuring  the  in¬ 
testine,  the  safer  is  it  to  give  carbohydrate.  FTonfer- 
mentable  carbohydrates  are,  as  we  told  you  in  the 
second  lecture,  composed  of  mixtures  of  dextrin  and 
maltose  and  can  be  offered  as  Mead’s  Dextri-Maltose, 
Mellin’s  Food,  Horlick’s  Malt  Food  (not  Malted  Milk), 
etc.  Remember,  these  substances  are  carbohydrates, 
and  under  no  circumstances  baby  foods. 

Our  treatment  then  for  these  milder  conditions  would 
be : 

Hunger  for  twelve  to  twenty-four  hours,  not  forget¬ 
ting,  however,  to  keep  up  a  sufficient  supply  of  water 
to  the  baby.  During  this  hunger  period  the  baby’s 
vomiting  and  diarrhea  empties  his  digestive  tract  of  all 
irritants.  It  is  not  necessary  to  give  calomel  and  castor 
oil,  unless,  perhaps',  foreign  stubistances  have  been 
eaten ;  for  the  baby,  as  a  rule,  can  well  take  care  of  him¬ 
self.  If  you  suspect  that  the  trouble  is  due  not  to  the 
milk,  but  to  corn  or  cucumbers  or  watermelon,  a  dose 
of  castor  oil  and  a  mild  colonic  flushing  may  do  no 
harm,  if  given  once. 

2.  After  this  hunger  period,  we  must  start  food. 
To  dilute  our  whey,  we  give  one  part  milk,  two  parts 
water.  To  this  mixture  we  add  1  or  2  per  cent  of  non¬ 
fermentable  carbohydrate.  We  boil  these  together  and 
in  six  feedings  give  a  total  of  6  to  10  ounces  in  twenty- 
four  hours,  always  keeping  up  the  supply  of  water. 
We  can  gradually  increase  about  3  ounces  to  the  twenty- 
four  hours  total  every  day  or  two  until  we  have  reach- 


69 


ed  our  maximum  quantity,  depending  upon  the  baby’s 
age.  Having  reached  our  maximum  total  quantity, 
gradually  we  increase  the  carbohydrate  to  5  per  cent. 
In  all  this  treatment  our  guide  must  not  he  so  much 
the  stool  as  the  baby’s  weight  curve : 


At  (a)  we  have  withdrawn  food;  a  gradual  loss  of 
perhaps  7  to  8  ounces  results  during  the  next  few  days. 

At  (b),  after  twelve  to  twenty-four  hours  hunger, 
we  give  the  baby  his  6  to  10  ounces.  We  hold 
him  there  until  at  (c)  the  curve  has  straghtened  out, 
and  then  we  gradually  increase.  Remember,  the  body’s 
curve  is  the  index  of  his  general  nutrition,  and  although 
this  dyspepsia  is  almost  exclusively  a  local  intestinal 
affair,  still  the  loss  of  weight  resulting  from  improper 
treatment  proves  that  the  baby’s  general  nutrition  also 
can  and  does  suffer,  and  if  we  keep  this  broad  picture 
before  our  minds  we  shall  be  less  likely  to  err  badly. 

In  some  cases  physicians,  instead  of  giving  water 
during  the  first  day,  give  cereal  waters — barley  gruel, 
etc.  This,  in  many  cases,  is  fully  as  efficient  as  is  plain 
t  water.  The  dangers,  however,  are  two : 

a.  The  physician,  in  his  carelessness,  the  mother  not 
knowing  that  barley  water  is  a  starvation  diet,  forgets 
to  add  food,  allows  the  baby  to  remain  on  barley  water 
for  days;  and,  after  a  period  of  four,  five,  or  six  days, 
the  child  rapidly  goes  down  into  the  condition  of 
Czerny’s  Starch  Injury,  or,  as  we  shall  call  it,  “De¬ 
composition.” 

h.  Sometimes,  after  the  baby  has  been  on  barley 
water,  for  reasons  which  are  not  clear,  upon  the  addi¬ 
tion  of  milk  to  the  diet,  fermentation  again  becomes 
active  in  the  intestine,  and  diarrhea  returns. 

For  dyspepsias  in  older  children  the  same  principles 
hold  good.  We  shall  refer  to  them  later. 


70 


Gentlemen,  suppose  we  are  ignorant  of  the  food  factor 
in  this  dyspepsia;  suppose  we  have  attributed  the  con¬ 
dition  to  something  else;  suppose  we  have  quieted  the 
child  with  opiate  and  allayed  the  mother’s  tears;  sup¬ 
pose  we  have  thoroughly  cleaned  out  the  child  with 
calomel  and  castor  oil;  and  then  suppose,  in  our  folly, 
thinking  the  baby  must  have  food,  we  offer  the  child  one 
of  those  mixtures  high  in  the  whey  elements  of  the  milk 
and  rich  in  fermentable  carbohydrate,  such  as  butter¬ 
milk  with  sugar  or  skimmed  milk  with  sugar.  Can 
you  grasp  the  result  ? 

Shortly  we  are  called  to  see  a  desperately  sick  baby. 
The  child  is  feverish  and  lies  in  semi-stupor.  The 
sunken  cheeks,  the  sharp  nose,  the  ashen,  mud-colored, 
wrinkled  skin,  the  cold  extremities  all  show  great  loss  of 
weight  and  great  prostration.  Intense  watery  diarrhea 
drains  the  body  of  its  food  pulls  out  the  very  building 
blocks  of  the  tissues.  The  pulse  is  rapid  and  weak. 
Lying  apathetically  in  his  bed,  our  little  patient  no 
longer  interests  himself  in  his  surroundings.  The  barely 
closed  lids  show  the  well-nigh  glassy  eves  fixed  unin- 
telligently  upon  one  corner  of  the  room.  Occasionally 
he  wakes  for  a  moment,  looks  at  us,  cries  fretfully,  and 
again  wanders  off  into  apathy.  The  breathing  is  charac¬ 
teristic,  deep,  tireless,  rapid,  unceasing,  like  the  air 
hunger  of  diabetic  coma.  Occasionally  one  of  the  almost 
limp  extremities  is  moved  slightly.  Sometimes  these 
take  on  cataleptic  attitudes.  The  arms,  particularly,  are 
apt  to  assume  the  position  typical  to  a  prize  fighter. 
The  urine  may  show  sugar,  albumin,  and  casts. 

Examination  reveals  an  enlarged  liver. 

What  have  we  done,  gentlemen?  We  have  produced 
a  wonderful,  a  terrible  clinical  picture.  We  have  pro¬ 
duced  the  “Alimentary  Intoxication”  of  Finkelstein. 
For  this  description  the  pediatrics  world  forever  must 
be  grateful. 

.  Gentlemen,  we  have  spoken  to  you  about  the  im¬ 
portance  of  food  reactions.  Listen  carefully:  If  in 
this  stage  we  offer  our  patient  a  full  bottle  of  his  diet,  if 
we  offer  him  any  large  quantity  of  food,  his  weight 
curve  sinks  precipitately,  vertically,  downward  to 
rapid  death.  We  have  killed  our  baby.  Ho  surer  way 
have  we  of  doing  this  than  by  offering  him  food;  no 
surer  way  have  we  of  saving  him  than  by  removing  food. 


71 


If  at  point  “A”  in  the  period  of  his  dyspepsia,  we 
have  mistreated  our  patient,  so  that  steady  progression 
has  thrown  him  into  the  stage  of  intoxication,  at  “B,” 
addition  of  food  brings  the  fatal  drop;  withdrawal  of 
food  straightens  out  the  curve  and  the  child  is  saved. 
What  more  beautful  illustration  has  one  of  the  effects 
of  food  than  this  clinical  observation,  than  this  so- 
called  paradoxical  reaction  of  Finkelstein”  ?  The 
food  which  would  cause  a  normal  baby  to  gain,  causes 
destruction ;  the  hunger  which  causes  a  normal  baby  to 
lose  is  salvation. 

Gentlemen,  what  processes  are  involved  in  this  radi¬ 
cal  change  in  the  progress  of  the  mild  dyspepsia  to  the 
deadly  intoxication  ?  Listen  carefully :  This  progress 
is  one  of  transition  from  a  mild,  local,  intestinal  dis¬ 
turbance  to  the  severest  “disturbance  of  nutrition.”  In 
the  mild  dyspepsia,  constitutional  symptoms  do  not 
predominate.  The  acids  formed  irritate  the  mucous 
membranes  slightly  and  cause  diarrhea,  but  nutrition  is 
not  badly  affected,  as  shown  by  the  relatively  slight  loss 
of  weight.  Now  note  the  progress.  Increasing  acid  form¬ 
ation  begins  to  injure  the  intestine  wall.  The  acids  are 
now  sufficient  to  interfere  with  the  digestive  enzymes. 
Fat  is  no  longer  properly  digested,  and  its  split  products 


i 


72 


aid  in  increasing  the  damage.  In  this  acid  medium  new 
types  of  bacteria  flourish,  bacteria  which  can  attack  the 
fat,  producing  intense  irritants. 

Before  these  combined  assaults  the  intestinal  wall 
begins  to  fail.  The  membrane  is  no  longer  imperme¬ 
able  to  attack.  Its  weakened  strength  cannot  be  de¬ 
tected  by  the  microscope ;  it  can  be  by  physiological  ex¬ 
periment.  Now  for  the  first  time  do  undigested  food 
substances  pass  through  the  membrane  into  the  body. 
We  have  not  seen  these  undigested  substances  entering 
the  body,  but  our  experiments  have  found  them  as  they 
leave.  We  feed  children  in  this  condition  lactose,  and 
lactose  appears  in  the  urine.  We  feed  these  children 
foreign  protein,  and  foreign  protein  appears  in  the 
urine.  Gentlemen,  the  process  of  digestion  is  to  pre¬ 
pare  foodstuffs  for  the  use  of  the  tissues.  Remember, 
undigested  foodstuffs  circulating  in  the  body  fluids  are 
poison.  See  the  possibilities  of  this  conception.  The 
mild  dyspepsia  has  progressed  so  that  now  the  entire 
body  has  become  severly  and  dangerously  involved. 

We  can  paint  almost  any  picture.  We  see  undigested 
protein  and  poisonous  products  of  the  fat  taken  into 
the  circulation.  We  see  the  tissues  bathed  in  strong  so¬ 
lutions  of  sugar;  of  strong  salt.  We  see  innumerable 
products  of  bacterial  activity  rapidly  entering  the  sys¬ 
tem.  We  see  chaos  where  we  should  see  order. 

Small  wonder  at  the  multitude  of  clinical  symptoms. 
Convulsions,  strabismus,  and  cerebral  cry  may  suggest 
meningitis.  Gastro-intestinal  effects  may  be  great 
enough  to  resemble  cholera.  But  in  all  cases,  remember 
that  certain  symptoms  will  be  constant :  the  rapid  loss 
of  weight,  the  toxic  acidosis  type  of  breathing,  the  dis¬ 
turbed  consciousness. 

The  examination  of  the  food  and  the  total  excretion 
of  these  children  in  contrast  to  the  mild  dyspepsia 
shows  a  considerable  loss  of  body  substance.  Pro¬ 
tein,  fat,  and  minerals  are  thrown  out  of  the  body  by 
the  rapid  intestinal  movements,  and  the  urine  shows 
the  most  profound  changes  of  metabolism. 

There  is  a  tremendous  loss  of  water,,  due,  perhaps, 
not  so  much  to  the  increased  bowel  movement,  for  this 
is  compensated  by  the  decreased  urine,  but  due  to  the 
tireless,  rapid  deep  respiration.  In  this  condition,  then, 
are  we  dealing  with  an  infinitely  more  important  prob- 


73 


lem  than  local  intestinal  diseases.  As  the  mild  tonsil- 
itis  results  in  endocarditis,  as  the  insignificant  wound 
ends  in  deadly  tetanus,  so  may  the  simple  dyspepsia 
lead  to  a  profound  “disturbance  of  nutrition” — the  “Ali¬ 
mentary  intoxication.” 

diagnosis 

The  history  in  a  way  makes  the  diagnosis.  Improper 
feeding,  followed  by  a  disturbance,  such  as  we  have  de¬ 
scribed,  is  in  almost  all  cases  “alimentary  intoxication.” 
In  our  history,  however,  before  excluding  this  condition, 
we  must  not  focus  too  carefully  upon  the  feeding  alone, 
but  must  recognize  the  new  factors,  which  by  their  ef¬ 
fect  upon  the  baby’s  general  condition  also  predispose. 
The  same  factors  are  those  to  which  we  referred  in  dys¬ 
pepsia,  viz.,  age,  constitution,  infections,  poor  nursing, 
and  heat.  We  have  learned  that  this  condition  never 
develops  primarly  in  a  well  child.  There  must  have 
been  a  preceding  state  of  dyspepsia  or  decomposition. 
The  latter  we  shall  consider  in  the  next  lecture. 

The  diagnosis  is  definitely  established  upon  with¬ 
drawal  of  food : 


74 


If,  after  twenty-four  hours  of  hunger,  the  loss  of 
weight  ceases,  the  temperature  drops  to  normal,  the 
diarrhea  improves — the  latter,  however,  not  being  ab¬ 
solutely  essential — we  make  a  positive  diagnosis  of  ali¬ 
mentary  intoxication. 


TREATMENT 

1.  Gentlemen,  during  the  first  twenty-four  hours  the 
child  must  hunger.  During  this  day  the  diarrhea  and 
the  vomiting  will  empty  the  intestinal  tract  of  irritants. 

2.  Under  no  circumstances  shall  we  give  calomel,  cas¬ 
tor  oil,  or  any  other  irritating  drug.  See  what  one 
does.  J ust  think !  The  intestines  are  acting  as  rapidly 
as  possible  to  rid  themselves  of  irritants.  They  are 
moving  just  as  quickly  as  they  can;  you  can’t  make 
them  move  any  more  quickly;  all  that  you  are  doing 
with  these  drugs  is  to  increase  injury.  What  the  intes¬ 
tine  needs  is  not  stimulation;  it  needs  a  rest.  For  this 
same  reason  we  would  not  injure  the  stomach  and  in¬ 
testines  by  getting  a  big  pump  and  repeatedly  washing 
out  the  stomach  and  flushing  out  the  bowels.  Leave 
them  alone.  They  will  take  care  of  themselves  if  you 
give  them  only  half  a  chance.  If  your  aim  in  using 
these  drugs  is  intestinal  asepsis,  your  hope  is  in  vain! 
Ho  drug  is  known  which  wTill  make  the  intestinal  con¬ 
tents  sterile.  Indeed,  animals  raised  with  sterile  intesti¬ 
nal  tracts  live  only  a  short  while.  Barrels  of  medicine 
haven’t  nearly  the  effect  of  a  slight  change  in  diet. 

In  addition  to  the  great  principle  of  physiologic  rest, 
during  these  twenty-four  hours  we  can  aid  our  little 
patient  in  other  ways : 

a.  ITe  is  suffering  greatly  from  loss  of  water;  we 
must  supply  fluids.  Give  him  all  the  water  he  wants. 

b.  The  use  of  a  little  salt  will  aid  him  greatly  in 
retaining  water  in  his  body.  Simply  take  a  little  sur¬ 
gical  salt  solution — physiological  salt  solution,  made  by 
adding  a  teaspoon  of  salt  to  a  pint  of  water;  dilute 
this  to  half  strength,  sweeten  it  with  a  little  saccha¬ 
rine,  and  offer  the  baby  3  to  4  ounces  by  mouth  during 
the  first  twenty-four  hours.  This  aids  him  in  retaining 
water ;  but  do  not  give  over  this  amount  or  you  will 
produce  edema  and  throw  too  great  a  strain  upon  the 
heart.  Edema  readily  results  in  these  cases. 


75 


c.  Our  little  child  may  need  to  be  stimulated.  Under 
these  conditions^  brandy,  in  doses  of  10  to  15  drops, 
every  few  hours,  caffein  citrate  in  doses  of  *4  of  a  grain, 
may  be  given  by  mouth.  Infinitely  more  effective  is 

'  the  hypodermic  use  of  10  to  15  minims  of  a  10  per 
cent  solution  of  camphor  in  oil,  repeated,  when  neces¬ 
sary,  every  few  hours.  Personally,  I  have  come  to 
place  more  and  more  confidence  in  adrenalin.  One  reads 
very  little  of  this  in  medical  discussions;  but  from 
my  own  observations,  I  am  absolutely  convinced  that 
in  the  failing  pulse,  and  sinking  blood  pressure  of  this 
condition,  just  as  in  surgical  shock,  hypodermic  in¬ 
jections  of  2  to  3  minims,  repeated  every  two  or  three 
hours,  are  of  great  value.  In  my  own  studies  I  have 
found  that  the  blood  pressure  is  raised  and  held  up  for 
periods  of  an  hour  following  injection  probably  by  the 
gradual  absorption,  resulting  from  subcutaneous  rather 
than  intravenous  use. 

d.  During  this  first  day  treatment  of  the  mother  is 
a  most  important  consideration.  She,  in  her  maternal 
anxiety,  demands  that  we  do  something.  The  substitu¬ 
tion  of  tea  for  water  is  a  great  help.  From  our  stand¬ 
point,  children  take  it  well,  like  it,  and  we  supply  fluid 
to  the  tissues.  We  can  explain  to  the  mother,  however, 
that  in  tea  we  have  caffein,  which  is  a  great  stimulant, 
tannic  acid,  which  will  tend  to  combat  the  diarrhea,  and 
we  can  make  the  matter  more  impressive  by  adding  a 
little  saccharine  tablet  for  sweetening.  We  can  busy  the 
mother,  during  the  first  day,  with  the  general  care  of 
the  baby,  keeping  him  warm,  offering  with  a  medicine 
dropper  small  doses  of  our  salt  solution  and  perhaps  a 
little  medicine  at  regular  intervals.,  but,  under  no  cir¬ 
cumstances,  shall  we  be  influenced  to  diverge  radically 
from  our  principles. 

e.  What  medication  shall  we  use  for  the  intestine? 
Gentlemen,  if  you  have  understood  the  principles  of 
this  disturbance,  you  see  that  a  little  alkali  can  be  rea¬ 
sonable  and  logical.  Chalk  mixture  with  its  calcium  can 
be  given  in  doses  of  several  teaspoons  every  few  hours. 
It  is  interesting  to  see  how  the  older  men  empirically 
arrived  at  this  remedy;  but,  gentlemen,  under  no  cir¬ 
cumstances  place  your  faith  in  medicine ;  medicines  are 
simply  insignificant  aids  in  our  treatment  compared  to 
the  enormous  influences  exerted  by  food. 


76 


/.  While  in  the  stage  of  simple  dyspepsia  ordinary  di¬ 
lution  of  the  milk  and  reduction  of  the  carbohydrate 
suffices  for  a  cure,  in  this  condition  we  are  reduced  to 
the  use  of  two  foods  only.  These  are  breast  milk  or, 
if  this  is  not  obtainable,  the  famous  “Eiweiss  Milch,” 
or  Albumin  Milk  of  Einkelstein  and  Meyer. 

The  principles  upon  which  this  food  is  based  are 
just  ordinary  common  sense.  If  carbohydrate  ferments, 
it  must  be  reduced.  If  whey  so  injures  the  intestines  as 
to  enhance  fermentation,  the  whey  must  be  diluted. 
If  casein,  by  calling  forth  alkaline  intestinal  juice,  by 
aiding  putrefaction,  by  combining  with  calcium,  over¬ 
comes  fermentation  and  makes  the  intestine  alkaline, 
protein  must  be  increased.  With  this  object  in  view 
Einkelstein  and  Meyer  set  about  making  the  above  mix¬ 
ture.  It  was  originally  made  as  follows : 

(a)  To  1  quart  of  raw  milk  add  enough  ferment 
to  cause  coagulation  and  formation  of  large  casein 
curds.  Any  milk-coagulating  ferment  will  do.  In  Chi¬ 
cago,  we  use  Chymogen  put  up  by  Armour  &  Co.,  in 
amounts  of  1  dram  to  a  quart  of  milk. 

(b)  In  order  to  separate  the  curd  from  the  whey, 
we  filter  this  mixture,  letting  it  hang  in  a  cloth  bag  for 
an  hour.  During  this  process  all  the  whey  drips  off 
and  the  pure  casein  curd  remains. 

(c)  This  casein  curd  is  put  through  a  fine  hair 
sieve,  the  wire  meshes  of  which  must  be  finer  than  a 
window  screen.  You  understand  if  the  casein  is  fed 
in  large  pieces  it  will  not  exert  its  physiological  effects, 
for  only  a  small  amount  of  it  will  be  exposed  to  the 
intestinal  juices  and  to  the  bacteria.  The  center  of  the 
curd  will  be  untouched.  The  success  of  the  mixture, 
then,  depends  upon  a  very  fine  division  of  the  casein. 
It  must  be  put  through  the  sieve  two  or  three  times. 

( d )  To  the  finely  divided  curd  we  add  1  pint  of 
buttermilk.  Buttermilk  supplies  salts,  and  a  baby  must 
have  salts  to  live.  You  ask  why  a  pint  of  whole  milk 
or  skimmed  milk  will  not  suffice.  Whole  milk,  you  re¬ 
member,  contains  fat,  which  we  are  glad  to  reduce  in 
these  severe  cases.  Whole  milk  and  skimmed  milk 
both  contain  lactose,  which  is  very  fermentable.  But¬ 
termilk  not  only  has  no  fat,  but  also  has  very  little 
lactose,  and  possibly  the  lactic  acid  may  be  of  some 
aid. 


77 


(e)  Enough  water  is  added  to  this  mixture  to  make 
1  quart.  The  mixture  is  now  boiled,  stirred  with  a 
cutting  motion  to  prevent  the  reformation  of  large 
curds,  and  divided  into  bottles.  Upon  offering  them  to 
the  baby  these  bottles  must  not  be  heated  above  body 
temperature,  or  large  curds  again  will  form. 

You  see  now,  gentlemen,  what  this  mixture  con¬ 
tains  : 

( a )  We  have  the  casein  of  1  quart  of  milk  plus  that 
of  1  pint  of  buttermilk. 

( b )  We  have  the  whey  of  1  pint  of  buttermilk;  thus 
the  whey  has  been  reduced  to  one-half. 

( c )  We  have  almost  no  lactose. 

Everything  in  this  mixture  speaks  for  alkali  forma¬ 
tion;  speaks  against  acid  formation.  What  a  curious 
world  this  is !  In  the  olden  times  we  used  to  throw 
away  the  curd  and  use  the  whey;  now  we  throw  away 
the  whey  and  use  the  curd.  This  is  an  ideal  mixture  to 
overcome  the  fermentative  stool,  to  neutralize  the  in¬ 
testinal  reaction,  and  to  stop  the  diarrhea.  Shall  we 
feed  this  mixture  to  the  baby?  What  an  ideal  mixture 
is  this  to  hill  our  little  patient!  You  look  somewhat 
surprised.  You  have  made  just  the  same  mistake  that 
Finkelsteiu  and  his  assistants  did.  Reports  came  rap¬ 
idly  from  all  over  the  world  protesting  against  the 
use  of  his  mixture.  Rot  long,  however,  before  the  error 
was  detected.  Finkelstein  and  Meyer  had  made  the  same 
mistake  that  we  have  seen  repeated  time  and  time  again. 
They  focused  too  carefully  upon  the  stool  and  forgot 
the  baby!  True  enough,  the  intestinal  condition  was 
cured;  the  stools  became  alkaline  and  constipated,  but 
the  baby  died!  Gentlemen,  listen  carefuly  one  moment: 
The  baby  died  from  lack  of  carbohydrate.  In  our  in¬ 
tense  desire  to  treat  the  diarrhea,  we  forgot  the  baby. 
The  child  must  have  carbohydrate  to  live,  and  this  baby 
was  getting  an  amount  insufficient  even  for  life.  With¬ 
out  going  too  much  into  detail,  it  was  learned  that  in 
albumin  milk  it  is  perfectly  safe  to  give  at  least  3  per 
cent  carbohydrate.  If  this  is  given  in  the  form  of  non- 
ferment'able  carbohydrates,  such  as  dextrin-maltose 
preparations,  no  harm  will  result.  So,,  in  making  up 
albumin  milk,  never  commit  the  fatal  error  of  omitting 
3  per  cent  carbohydrate  in  every  quart  of  mixture.  In 
offering  the  albumin  milk,  instruct  the  mother  to  use 


78 


a  large  nipple,  as  some  of  the  casein  curds  may  stick 
in  a  small  one.  You  may  also  add  a  little  saccharine 
for  sweetening,  for  when  the  child  gets  stronger  he 
may  object  to  the  taste  of  the  buttermilk. 

In  offering  the  baby  breast  milk  or  albumin  milk, 
shall  we  give  him  a  full  bottle?  Gentlemen,  to  do  so 
means  death.  Even  if  a  wet  nurse  be  obtainable,  if  we, 
thinking  that  breast  milk  is  an  ideal  food,  recklessly 
put  the  child  to  nurse,  we  probably  shall  lose  him  in  a 
very  few  hour^.  With  the  intense  degree  of  fermen¬ 
tation  that  is  existing  in  the  intestine,  the  high  amount 
of  sugar  in  breast  milk,  even  though  it  be  in  the  healing 
breast  milk  whey,  may  ferment  and  increase  the 
damage. 

In  all  cases  our  techinque  must  be  extremely  rigid 
and  exact. 

1.  Keeping  up  the  same  general  treatment  of  the  first 
day:  stimulation  and  fluids  in  the  form  of  tea,  we  offer 
ten  feedings  of  about  %  ounce  each  of  food. 

2.  The  next  day  we  increase  these  to  ten  feedings  of 
from  two-thirds  to  one  ounce,  depending  upon  the 
severity  of  the  condition. 

3.  The  following  days  we  may  increase  gradually  to 
ten  feedings  of  1%  ounces. 

Here  we  must  wait  and  note  the  reaction  of  our 
weight  curve : 


We  hold  our  food  perfectly  constant  at  10  x  1% 
independent  of  the  stools  until  the  weight  curve  has 


79 


straightened  out.  If  the  weight  curve  .still  sinks,  if  the 
diarrhea  continues,  under  no  circumstances  make  any 
change  in  the  food.  The  danger  of  a  change  is  much 
greater  than  the  danger  of  leaving  it  as  it  is.  When, 
however,  the  weight  curve  has  become  horizontal,  we 
safely  may  continue  to  increase  gradually  up  to  the 
maximum  quantity;  that  is,  about  3  ounces  of  the  mix¬ 
ture  for  every  pound  of  the  baby’s  weight.  When  we 
reach  our  maximum  quantity,  slowly  we  increase  our 
carbohydrate  to  5  per  cent.  After  a  few  weeks  we  re¬ 
turn  to  an  ordinary  milk  mixture. 

I  have  gone  into  such  detail,  gentlemen,  not  because 
I  want  you  to  remember  the  technique  exactly  of  making 
albumin  milk,  but  because  I  want  you  to  remember  the 
principles  upon  which  this  technique  is  based.  If  you 
have  the  principles,  then,  no  matter  where  you  are, 
what  means  are  at  your  disposal,  simply  make  up  a 
combination  of  high  protein,  low  whey,  and  nonfer- 
mentable  carbohydrate.  Never  commence  with  large 
doses,  but  following  a  hunger  period,  being  guided  by 
your  weight  curve,  offer  gradually  increasing  amounts. 

These  principles  you  can  apply  to  your  older  chil¬ 
dren — children  of  one  to  three  years  of  age : 

1.  Hunger  with  tea  and  fluids  for  the  first  day. 

2.  Reduce  the  whey  by  removing  milk  or  diluting  it 
to  one-third  or  one-half. 

3.  Increase  the  protein  by  giving  scraped  meat,  cot¬ 
tage  cheese,  and  curds  of  milk. 

4.  Give  nonfermentable  carbohydrates,  Zwieback,  and 
mashed  potatoes  and  cereals,  such  as  corn  starch,  cream 
of  wheat,  and  arrowroot. 

5.  Supply  salts  best  as  vegetable  purees. 

Don’t  forget  the  hunger  period ;  don’t  forget  fluids, 
and,  above  all  thingsi,  don’t  forget  the  tiny  doses  of  food 
in  the  begining  of  the  treatment. 

Gentlemen,  if  you  are  thoroughly  conversant  with 
these  principles,  no  matter  where  you  are,  no  matter 
how  primitive  the  home,  you  will  be  always  completely 
master  of  the  situation. 


LECTURE  VI 


DECOMPOSITION 

Gentlemen,  in  the  previous  lectures  we  discussed  three 
of  the  clinical  types  of  nutritional  disturbance  which 
Finkelstein  called  to  our  attention.  You  remember  that 
it  was  he  who  for  the  first  time  clearly  and  emphati¬ 
cally  laid  great  importance  upon  the  factors  of  nutri¬ 
tion  and  food  in  the  production  of  what  we  previously 
had  called  “The  diarrheal  diseases  of  infants.”  That 
many  of  his  first  explanations  were  incompletev,  that 
many  of  his  views  will  again  be  amplified,  there  can  be 
no  doubt.  But  the  service  he  has  done  us  is  immeas¬ 
urable.  In  the  lectures  on  disturbed  balance,  dyspep¬ 
sia,  and  intoxication  we  have  given  you  these  three 
clinical  pictures  as  he  described  them.  Today  we  will 
concern  ourselves  with  the  last  of  the  four  groups,  the 
subject  of  decomposition.  Names,  of  course,  make  no 
difference.  It  is  perfectly  immaterial  what  names  we 
use,  provided  we  remember  the  clinical  picture.  Finkel¬ 
stein  in  describing  this  condition  did  not  describe  a  new 
disease  or  even  a  new  clinical  syndrome.  He  did  give 
us,  however,  a  new  name  and  a  new  explanation,  the 
new  name  being  decomposition ,  and  that  term  being 
used  to  explain  and  to  emphasize  that  destruction  was 
occurring  in  the  baby’s  body.  You  gentlemen  have 
known  this  condition  under  the  names  of  atrophy,  mar¬ 
asmus,  and  malnutrition.  These  conditions  are  fa¬ 
miliar  to  you  all.  Finkelstein,  however,  does  not  think 
that  these  terms  describe  accurately  the  complicated 
processes  that  are  being  evolved  in  the  child’s  body,  and 
hence  changes  the  term.  It  is  hardly  necessary  for  me 
to  describe  to  you  the  picture.  Doubtless  you  have  seen 
it  often  in  your  practice.  A  tiny,  undernourished  in¬ 
fant,  weight  far  below  normal,  lies  restless  and  crying 
in  its  bed  or  in  its  mother’s  arms.  Simultaneously 
one  notices  the  pallid,  blue,  wrinkled,  tissue-paper  like, 
fat-free  skin,  and  the  whole  bony  skeleton  that  seems 
to  protrude  right  through  it.  The  face  is  that  of  a  tired 
old  man.  The  large,  deep-seated  eyes  move  restlessly 


81 


about;  then  fix  upon  you  with  an  appealing,  uncanny 
stare.  The  large  mouth,  with  its  thin  reddish  lips, 
opened  wide  in  a  never-ceasing  fretful  cry,  is  in  strik¬ 
ing  disproportion  to  the  small  weazened  face,  and  into 
this  mouth  the  child  inserts  one  or  both  fists  and  sucks 
and  chews  them  in  blind  greed.  His  peevish  tones 
reveal  perpetual  misery.  Through  the  emaciated  skin 
of  the  thorax  the  bony  framework  in  all  its  detail  pro¬ 
trudes,  and  through  the  tissue-paper  thinness  of  the 
skin  and  muscles  of  the  abdomen  the  abdominal  viscera 
may  reveal  their  outlines  and  movements.  On  the  ex¬ 
tremities  the  skin  hangs  in  large  folds,  apparently  right 
over  the  bones. 

In  sharp  contrast  to  the  condition  of  intoxication, 
this  child’s  consciousness  is  undisturbed — if  anything, 
excited.  You  remember  how  the  child  with  intoxication 
lies  drowsily  upon  the  bed,  eyes  fixed  apathetically  on 
one  corner  of  the  room,  then  arouses  himself  with  a 
short  cry  temporarily,  and  again  lapses  into  semicon¬ 
sciousness.  This  child,  the  child  with  the  decomposi¬ 
tion,  is  continuously  on  the  alert,  cries  pitifully,  never 
ceasing,  and,  indeed,  never  seems  to  sleep.  You  re¬ 
member  the  child  with  the  intoxication  had  the  rapid, 
tireless,  never-ceasing  respiration.  This  child  has  the 
slow,  feeble,  irregular  type.  In  the  intoxication  the 
pulse  is  rapid.  In  this  child  the  pulse  is  slow  and  weak. 

Normally,  the  pulse  in  an  infant  ranges  around  120. 
In  this  child  it  may  be  80  or  below.  In  the  intoxication 
stage  the  temperature  is  usually  elevated.  In  the  de¬ 
composition  the  temperature  is  usually  subnormal,  the 
more  subnormal  it  is  the  worse  being  the  state  of  the 
disturbance.  Rarely  does  the  temperature  even  rise  to 
normal.  In  contrast  to  the  albuminuria,  glycosuria,  and 
the  casts  of  the  intoxication,  the  urine  of  this  child  is 
normal.  The  intoxication  suggests  acute  poisoning,  the 
decomposition  chronic  collanse. 

Symptoms  of  the  gastro-intestinal  tract  vary  with  the 
food.  Vomiting  is  not  unusual.  Stools,  however,  de¬ 
pend  to  a  large  extent  upon  the  diet.  When  the  diet  is 
large,  particularly  when  it  is  high  in  carbohydrate,  we 
usually  have  a  fermentative  process  in  the  intestine  and 
a  resulting  diarrhea.  Such  a  process  is  very  easy  to 
understand  when  we  consider  that  the  intestinal  tract 
suffers  in  its  general  nutrition  as  much  as  does  every 
6 


i 


82 


organ  of  the  body.  It  is  perfectly  rational,  then,  to 
assume  that  the  functionally  injured  intestinal  cells  of 
the  upper  digestive  tract  do  not  suppress  bacterial 
growth  as  they  do  in  the  normal  infant.  Consequently, 
any  improper  combination  of  food,  especially  mixtures 
rich  in  whey  and  carbohydrate,  will  readily  stir  up 
these  bacteria  to  growth,  and  in  the  resulting  fermenta¬ 
tion  are  formed  the  irritating  acid  products  which  lead 
to  dyspepsia  and  intoxication.  In  such  a  condition,  if 
high  fat  is  fed,  the  fat  will  be  whisked  through  the  in¬ 
testine  out  in  the  stool.  We  do  not  mean  to  be  too  dog¬ 
matic.  It  is  perfectly  reasonable  and  logical,  and  there 
is  also  some  good  evidence  to  show,  that  the  digestive 
ferments  are  not  very  active  in  this  condition,  and  we 
can  readily  understand  the  appearance  of  fat  in  the 
stools,  due  also  to  its  improper  digestion  and  assimila¬ 
tion.  We  believe,  however,  that  in  the  majority  of 
cases  the  fat  appears  passively  in  the  stool,  being  second¬ 
ary  to  the  primary  fermentation  of  the  carbohydrates. 

On  the  other  hand,  if  a  diet  high  in  protein,  low  in 
carbohydrate  and  whey,  is  given  the  stool  will  become 
alkaline  and  hard.  How  less  undigested  fat  will  appear. 
This  observation  supports  our  premise  that  the  fat  is 
really  the  secondary  factor.  Again,  the  smaller  the  diet 
the  less  likely  is  it  that  the  stool  will  be  diarrheal.  Per¬ 
haps  no  better  illustration  than  this  can  be  afforded  of 
the  dangers  of  being  guided  in  treatment  by  the  condi¬ 
tion  of  the  stools.  In  many  of  these  cases  babies  go 
down  and  die  in  collapse  with  typical  constipation.  Ho 
more  terrible,  no  greater  mistake  can  be  made  than  that 
of  focusing  all  one’s  attention  upon  the  character  of 
the  stool  (treating  the  stool  so  as  to  change  it  from  a 
diarrheal  type  to  a  constipated  type),  and  forgetting  the 
baby  in  the  meantime ;  allowing  the  baby  to  go  down  and 
to  die  in  the  collapse  of  hunger.  This  danger  can  be 
avoided  if  one  remembers  the  same  thing  that  we  have 
repeated  over  and  over  again,  that  the  stools  are  simply 
indications  of  what  has  been  put  into  the  intestinal  tract, 
of  the  way  that  food  has  been  handled,  and  are  only  a 
very  tiny  guide  to  us — simply  a  symptom — of  no  more 
importance  as  an  absolute  indication  for  therapy  than 
is  the  condition  of  the  baby’s  skin,  no  more  so  than  is 
the  condition  of  the  baby’s  heart  and  pulse,  no  more  so 
than  is  the  condition  of  the  baby’s  breathing.  They 


83 


constitute  simply  one  of  the  many  important  symptoms 
of  the  condition.  As  the  weakened  pulse  points  to  the 
failing  circulation,  so  do  the  abnormal  stools  point  to 
an  inefficient  digestive  tract.  This  latter  is  the  object 
of  our  therapy — not  the  stool.  In  all  these  conditions 
we  have  spoken  to  you  about  the  fundamental  import¬ 
ance  of  the  weight  curve  and  the  food  reactions. 


If  at  point  A — the  child  having  reached  the  typical 
stage  of  decomposition,  after  a  history  of  trouble  and 
gradual  loss  of  weight  for  several  months — we  feed  him 
with  a  diet  such  as  a  normal  child  should  have,  he 
will  lose  steadily  3  to  5  ounces  a  day,  go  down  and  die, 
not  infrequently  with  diarrhea  and  symptoms  of  in¬ 
toxication.  On  the  other  hand,  if  we  withdraw  food 
for  twenty-four  hours  we  find  a  very  sharp  drop  in 
weight,  the  curve  sinking  precipitately ;  the  child  dying 
with  all  the  symptoms  of  acute  collapse. 

Gentlemen,  no  more  terrible  mistakes  are  made  than 
letting  children  in  this  condition  hunger.  These  chil¬ 
dren  are  so  susceptible  to  all  influences  that  a  period  of 
hunger  of  twenty-four  hours,  which  would  scarcely  bo 
noticed  by  a  normal  baby,  other  than  by  its  loud  pro¬ 
tests,  results  in  rapid  death. 

In  addition  to  these  clinical  symptoms,  which  we 
notice  at  first  examination,  the  child  shows  great 


84 


-change  in  its  various  reactions  to  external  influences. 
These  children  are  particularly  susceptible  to  heat. 
They  are  particularly  susceptible  to  cold.  They  are 
susceptible  to  all  forms  of  violence.  They  are  readily 
injured  by  improper  nursing  and  care,  and  are  partic¬ 
ularly  likely  to  be  attacked  and  carried  away  by  the  va¬ 
rious  infectious  diseases.  It  is  well  to  remember  that 
these  children  sicken  from  causes  of  nutrition  and  die 
from  causes  of  infection.  Fatal  infections  are  very  fre¬ 
quently  overlooked,  not  only  by  the  careless  physician, 
but  by  the  most  experienced,  because  the  child  is  so 
weakened  in  his  reactions  that  even  the  most  virulent  in¬ 
fections  often  give  no  clinical  signs.  The  baby  is  too 
weak  to  react  with  temperature,  too  weak  often  to  show 
acceleration  of  the  pulse  or  of  the  breathing,  and  it  is 
only  postmorten  examination  which  reveals  how  fre¬ 
quently  our  little  patients  have  been  carried  away  with 
terminal  pneumonias. 


Hot  infrequently  we  find  masked  types  of  this  con¬ 
dition.  Upon  hasty  clinical  examination  we  might 
think  our  little  patient  was  only  in  a  stage  of  dyspep¬ 
sia  or  disturbed  balance.  We  would  become  a  little  sus- 


85 


picious,  however,  with  a  history  of  previous  very  irreg¬ 
ular  weight  curve  and  by  noting  in  our  examination 
deficiency  of  fat  in  the  subcutaneous  tissues,  and  skin 
of  a  rather  muddy  color.  Our  opinions  will  be  con¬ 
firmed  when  upon  treating  this  child  for  a  dyspepsia, 
upon  withdrawal  of  food,  we  find  not  the  usual  slight 
reaction  of  the  weight  curve,  but  a  sharp,  severe  drop 
of  many  ounces,  associated  with  subnormal  tem - 
perature. 

Gentlemen,  whenever  you  find  a  child  reacting  with 
symptoms  of  collapse,  and  particularly  subnormal  tem¬ 
perature  upon  withdrawal  of  food,  no  matter  how 
slight  you  thought  the  disturbance  was,  beware  that  you 
are  dealing  with  one  of  these  masked  types  of  decompo¬ 
sition.  Remember  that  that  child  of  all  children  is  sus¬ 
ceptible  to  all  external  influences — to  heat,  to  cold,  to 
infections,  to  poor  nursing,  particularly  susceptible  to 
improper  food — and  look  upon  him  as  a  critically  sick 
child. 

METABOLISM 

Having  studied  this  clinical  picture  carefully,  the 
next  thing  to  do  is  to  investigate,  if  possible,  the 
causes.  Don’t  misunderstand  me,  gentlemen.  It  has 
long  been  known  that  this  clinical  picture  can  be  pro¬ 
duced  by  tuberculosis,  syphilis,  wasting  diseases,  and 
other  conditions;  but  it  remained  for  Finkelstein  to 
show  that  a  great,  great  number  of  these  cases,  in 
which  the  etiology  had  previously  been  mysterious  or 
unknown,  was  based  upon  and  resulted  from  the  same 
fundamental  errors  of  nutrition  of  which  we  have 
spoken  so  frequently.  For  the  first  time  now  we  see 
this  condition  in  careful  clinical  examination  also 
studied  from  the  broad  viewpoint  of  nutritional  dis¬ 
ease.  If  one  places  •  such  a  child  upon  a  metabolism 
bed,  analyzes  carefully  the  food  taken  in,  and  the  stools 
and  urine  excreted,  one  finds  that  in  sharp  contrast  to 
dyspepsia  and  disturbed  balance  here  there  is  an  actual 
loss  of  protein  from  the  body.  The  body  is  losing 
more  protein  than  is  being  taken  in.  The  same  holds 
true  for  the  mineral  matter.  More  salts  are  lost  from 
the  body  than  are  contained  in  the  baby’s  food.  Indeed, 
much  of  the  clinical  picture  may  be  simulated  by 
mineral  hunger.  Such  experiments  are  very  difficult, 


86 


are  only  few  in  number,  but  are  of  tremendous  value. 
It  was  due  to  this  conception,  to  this  idea  that  an  actual 
destruction  was  taking  place  in  the  body,  that  Finkel- 
stein  changed  the  term  from  atrophy  to  decomposition. 

The  fat  metabolism  depends  upon  the  way  fat  is  ad¬ 
ministered.  If  it  is  given  in  a  mixture  rich  in  carbo¬ 
hydrate  and  whey,  the  fat  is  lost  in  the  resulting  diar¬ 
rhea.  If,  on  the  other  hand,  a  reasonable  quantity  is 
given  in  a  mixture  high  in  protein,  low  in  carbohy¬ 
drate  and  whey,  the  fat  is  well  taken  care  of. 

As  regards  the  carbohydrates,  the  body  itself  seems  to 
need  and  use  them  well.  The  great  difficulty,  however, 
is  to  get  these  carbohydrates  into  the  body,  for  with 
the  weakened  condition  of  the  intestine  permiting  bac¬ 
terial  growth  to  flourish  more  readily  than  normal,  car¬ 
bohydrates,  unless  given  very  carefully,  are  apt  to 
ferment  in  the  intestine  and  to  cause  diarrhea,  with 
pictures  varying  from  the  slightest  dyspepsia  to  the 
severist  intoxication. 

DIAGNOSIS 

The  diagnosis  of  this  condition  is  easy.  A  freshman 
medical  student,  a  novice,  a  beginner,  can  recognize  at 
once  such  a  clinical  picture.  It  makes  absolutely  no 
difference  what  name  we  give  it,  the  clinical  picture  is 
there;  and  it  remains  for  us  as  medical  men  not  to  be 
content  with  a  mere  diagnosis,  but  to  insist  upon  a 
diagnosis  of  the  cause,  of  the  etiology.  We  have  spoken 
before  of  tuberculosis,  syphilis,  and  wasting  disease. 
These  are  well  known;  but  of  the  new  factors,  the  fac¬ 
tors  of  tremendous  importance,  which  Finkelstein  has 
taught  us,  we  are  beginning  to  learn  more  and  more. 

1.  We  have  learned  that  this  condition  never  comes 
on  in  the  midst  of  health.  The  child  must  have  been 
sick  previously,  usually  with  a  history  of  ailing,  or  di¬ 
gestive  disturbance,  and  of  not  thriving  for  weeks  or 
months. 

2.  We  have  learned  that  age  is  of  importance.  The 
younger  the  child,  the  more  susceptible  is  he. 

3.  We  have  learned  that  diarrheas  are  of  tremendous 
importance — not  only  those  diarrheas  resulting  from 
improper  feeding  of  which  wre  have  spoken,  namely,  the 
dyspepsias,  but  also  the  diarrheas  resulting  from  true 
infection,  with  micro-organisms.  In  each  of  these 


87 


diarrheal  attacks  the  child  probably  loses  a  little  bit 
of  mineral  matter,  and  if  this  diarrhea  is  not  properly 
handled  the  loss  may  be  eventually  so  great  as  to  bring 
on  this  state  of  decomposition. 

4.  We  have  learned  that  long  continued  undernour¬ 
ishment  is  an  important  factor,  the  baby  not  getting 
for  a  sufficiently  long  time  a  great  enough  total  quantity 
of  food. 

5.  Hunger  is  a  tremendous  factor.  Particularly  hun¬ 
ger  applied  too  long  to  a  sick  child.  You  remember  in 
the  state  of  intoxication  when  the  weight  curve  was 
dropping  rapidly,  if  we  removed  food  at  A  for  twenty- 
four  hours  usually  the  drop  of  weight  ceased  and  the 
curve  straightened  out.  If  at  the  end  of  twenty-four 
hours,  at  B,  we  had  not  started  to  feed  that  baby  per- 


pearance  of  the  stools,  if  instead  of  feeding  that  baby 
we  had  prolonged  the  hunger  period,  guided  only  by  the 
condition  of  the  stools,  the  weight  curve  would  have 
swung  down,  taken  another  sharp  drop,  and  we  would 


88 


have  added  the  severe  calamity  of  a  decomposition  to 
the  great  dangers  already  besetting  our  little  patient. 

6.  Important  as  is  absolute  hunger,  partial  hunger  is 
perhaps  even  more  important  as  regards  frequency  in 
causing  this  condition.  By  partial  hunger  I  mean  one¬ 
sided  feeding,  such  as  feeding  with  barley  water  or  con¬ 
densed  milk.  Due  to  the  fault  of  the  physician  or  the 
carelessness  of  the  mother,  children  frequently  are  kept 
for  days  on  a  diet  of  barley  water.  This,  as  you  know, 
is  largely  carbohydrate,  and  after  four,  five,  or  six  days 
on  this  one-sided  feeding,  the  child  suffering  in  the 
meantime  from  insufficiency  of  protein,  salts,  and  fat, 
the  child  rapidly  reaches  the  state  of  decomposition. 
This  was  the  picture  that  Czerny  described  in  his  dis¬ 
cussion  of  starch  injury. 

Condensed  milk  is  perhaps  the  most  frequent  cause 
of  this  trouble.  Condensed  milk  is  very  high  in  sugar, 
low  in  the  other  elements,  as  protein  and  salts.  You  re¬ 
member  in  our  second  lecture  we  spoke  to  you  about 
the  qualities  that  sugars  have  of  pulling  water  into 
the  tissues  and  holding  it  there.  Due  to  the  high  sugar 
of  condensed  milk,  a  great  deal  of  water  is  retained  in 
the  tissues  of  these  children.  They  gain  for  some 
weeks  in  weight,  and  the  doctor  and  mother  are  de¬ 
lighted,  because  they  think  the  baby  is  doing  so  well. 
As  a  mater  of  fact,  however,  this  baby  is  starving,  his 
tissues  are  being  filled  with  water  and  his  body  cells  are 
dying  from  lack  of  protein  and  salt.  Only  the  severe 
reaction  following  a  slight  infection,  following  a  little 
exposure  to  heat  or  following  a  slight  error  in  diet  (such 
as  feeding  this  baby  a  little  too  much,  or  letting  him 
hunger  too  long),  shows  us  that  we  are  handling  a 
child  who  is  really  in  the  stage  of  decomposition.  Too 
long  exclusive  feeding  with  breast  milk  belongs  to  this 
class.  This  sounds  like  heresy,  gentlemen;  but  it  is 
nevertheless  true.  Too  long  exclusive  feeding  with 
breast  milk  is  a  not  infrequent  factor  in  the  production 
of  this  disturbance.  As  you  remember,  breast  milk  is 
very  low  in  protein  and  very  low  in  mineral  matter. 
After  the  child  gets  nine  months  or  more  in  age,  the  de¬ 
mands  of  his  body  are  greater  than  those  supplied  by  the 
contents  of  breast  milk.  Kept  too  long  upon  this  food 
exclusively,  without  the  addition  of  other  substances  to 


89 


cover  these  wants,  the  body  cells  suffer  from  lack  of  pro¬ 
tein  and  salts,  and  this  child  will  also  gradually  merge 
on  into  one  of  the  types  of  decomposition. 

7.  The  most  frequent  factor  of  all  is  probably  the 
fault  of  the  physician,  the  one  for  which  you  largely 
are  to  blame — I  don’t  mean  you  personally ;  I  mean  you, 
me,  all  physicians — namely,  the  improper  treatment  of 
the  mild  dyspepsias.  The  development  is  usually  as 
follows :  The  child  gets  a  slight  dyspepsia ;  the  phy¬ 
sician,  not  recognizing  the  food  nature  of  this  disturb¬ 
ance,  cleans  him  out  with  calomel  and  castor  oil,  gives 
him,  perhaps,  a  little  paregoric  to  check  the  bowels,  and 
makes  no  change  in  the  food.  Repetition  occurs  in 
perhaps  two  or  three  weeks.  Again  the  child  is  cleaned 
out  with  castor  oil,  again  is  he  subjected  to  the  irritating 
effect  of  calomel,  and  again  are  the  bowels  drugged  with 
paregoric;  but  the  food  is  unchanged.  May  be,  now, 
the  factor  of  hunger  is  introduced.  A  recurrence  of  the 
diarrhea  leads  to  the  same  treatment.  Perhaps  now  the 
physician  says:  “We  will  certainly  give  these  bowels 
a  rest.  We  are  going  to  let  this  baby  hunger  a  good 
long  time.”  No  factor,  gentlemen  is  more  important  in 
bringing  these  children  to  this  condition  than  is  this 
frequent  combination  of  improper  therapy  of  the  dys¬ 
pepsia  plus  the  improper  use  of  hunger.  Remember, 
gentlemen,  the  longer  the  hunger,  the  greater  the  dan¬ 
ger.  Remember,  the  more  frequently  repeated  the 
hunger  the  greater  the  danger ;  and  remember,  the 
closer  together  the  hunger  periods,  the  greater  the  dan¬ 
ger.  This  combination  of  improper  treatment  of  dys¬ 
pepsia  plus  the  improper  use  of  hunger  periods  is  the 
most  important  of  all  the  nutritional  factors  in  bring¬ 
ing  about  this  disturbance. 

Besides  all  these  above  errors  in  nutritional  tech¬ 
nique,  we  must  never  forget  that  the  same  other  in¬ 
fluences  are  also  effective  that  were  concerned  in  the 
production  of  the  dyspepsia  and  the  intoxication,  in¬ 
fluences  which  are  independent  of  our  skill — for  which 
we  are  not  to  blame — namely,  constitution,  infection, 
and  improper  care.  A  baby  with  a  weak  constitution,  a 
baby  who  has  repeatedly  had  infections,  a  baby  who  is 
improperly  cared  for,  is  jar  more  susceptible  to  any  nu¬ 
tritional  error  than  is  a  healthy  strong  child. 


90 


TREATMENT 

Gentlemen,  let  me  urge  upon  you  that  the  most  im¬ 
portant  treatment  by  far  is  prophylaxis.  If  we  handle 
our  dyspepsias  properly,  if  we  realize  the  importance 
of  the  state  of  disturbed  balance,  if  we  see  to  it  that 
the  well  baby  is  properly  nursed  and  cared  for,  properly 
dressed  and  properly  fed,  the  number  of  cases  of  de¬ 
composition  arising  from  nutritional  sources  will  be 
very  few  indeed. 

Once  having  developed,  however,  the  condition  is 
difficult  to  treat,  and  requires  a  careful,  definite  rou¬ 
tine.  Only  two  foods  can  we  rely  upon.  Just  as  in 
the  state  of  intoxication,  so  can  we  have  confidence 
only  in  breast  milk  or  albumin  milk.  In  either  case 
our  technique  must  be  about  the  same. 

During  the  first  day  the  child,  if  a  bad  diarrhea  is 
present,  may  be  allowed  to  hunger  from  six  to  at  the 
very  most  twelve  hours ;  never  under  any  circumstances 
over  twelve  hours.  Preferably,  he  should  miss  only  one 
or  two  bottles,  and  if  the  stools  are  only  a  few  in  num¬ 
ber,  he  need  miss  none.  During  this  period  the  same 
general  treatment  as  in  intoxication  may  be  employed, 
that  is,  the  use  of  stimulants,  the  use  of  water  and  tea, 
the  use  of  a  little  salt. 

Following  this  hunger  period,  or  if  no  diarrhea  be 
present,  absolutely  at  once  we  must  start  feeding.  Dur¬ 
ing  the  first  day  we  shall  offer  ten  feedings  with  a  total 
in  twenty-four  hours  of  10  ounces.  Gradually  we  in¬ 
crease  this  total  quantity,  adding  about  2  to  3  ounces  to 
the  twenty-four  hours  total  every  other  day,  until  we 
have  reached  our  maximum.  Our  maximum  with  albu¬ 
min  milk  is  3  ounces  for  each  pound  of  body  weight, 
that  is,  a  baby  weighing  7  pounds  shall  get  a  total  of  21 
ounces,  a  baby  of  9  pounds  shall  get  a  total  of  27  ounces. 
During  this  gradual  increase  of  our  diet  our  guide  is 
solely  and  simply  the  weight  curve.  Gentlemen,  let  me 
impress  upon  you  that  no  graver  mistakes  can  be  made 
than  letting  the  condition  of  the  stools  influence  your 
treatment.  We  are  interested  in  saving  the  baby.  The 
baby,  to  us,  is  infinitely  more  important  than  his  gastro¬ 
intestinal  canal.  If  to  save  the  baby  apparent  tempo¬ 
rary  neglect  of  all  symptoms  of  impaired  digestion  is 
necessary,  we  must  neglect  them.  The  gastro-intestinal 


91 


tract,  to  us,  is  simply  a  means  of  getting  food  to  this 
baby.  We  absolutely  must  give  him  food.  If  we  let  this 
one  clinical  symptom — the  symptom  of  the  stool — sway 
us  from  our  course,  though  we  may  correct  the  condition 
of  the  stool,  we  frequently  lose  our  patient.  Our  guide 
of  food  increase  shall  be  the  weight  curve.  To  illus¬ 
trate  : 


The  baby  has  been  sick  for  weeks,  the  curve  coming 
constantly  downward.  At  A  he  is  in  the  state  of  decom¬ 
position,  where  we  allow  him  to  hunger  or  feed  him 
small  quantities  of  food,  a  total  in  twenty-four  hours  of 
10  ounces.  Due  to  the  hunger  or  due  to  the  small  quan¬ 
tities  of  food,  he  continues  to  lose  weight  slightly.  We 
must  hold  him  at  this  stage  until  at  B  his  weight  curve 
has  straightened  out.  A  continuation  of  the  downward 
curve  to  C  shows  us  that  the  destructive  processes  still 
going  on.  With  the  destructive  process  still  continuing, 
we  are  in  no  condition  to  increase  our  diet,  nor  are  we  in 
a  condition  to  change  it  or  to  withdraw  it.  If  we  wish 
to  save  our  baby  we  must  hold  our  quantity  constant 
and  steady  until  this  weight  curve  has  straightened  out 
and  shown  to  us  that  destruction  is  ceasing  and  that  the 
baby  is  now  in  a  position  to  assimilate  some  nourish¬ 
ment.-  This  is  the  time  to  start  a  gradual  cautious 
increase  of  the  diet  according  to  the  schedule  we  have 
just  given  you.  If  the  hahy  is  breast  fed,  under  no 
circumstances  put  the  baby  to  the  breast  the  first  few 
days.  The  mother  must  squeeze  the  breast  milk  from 
her  breasts  into  a  clean  glass  and  the  baby  fed  these 
quantities  exactly  from  a  bottle  or  medicine  dropper . 


92 


When  the  weight  curve  has  finally  straightened  out — 
a  matter  of  a  few  days — we  sigh  with  relief,  for  the 
battle  is  won;  and  now,  after  the  child  has  started 
gaining  slightly,  it  is  perfectly  safe  to  put  the  child 
again  gradually  back  upon  the  breast. 

In  our  last  lecture  I  gave  you  in  detail  the  technique 
of  making  albumin  milk.  I  wanted  you  to  know  the 
original  process,  so  as  to  emphasize  to  you  the  principles 
upon  which  the  mixture  was  made.  You  remember  the 
principles  were  low  whey  and  low  carbohydrate  to  re¬ 
duce  the  factors  causing  fermentation,  high  protein  to 
increase  the  factors  causing  alkalinity  and  overcoming 
fermentation.  Today  I  want  to  give  you  a  simpler  tech¬ 
nique,  one  which  you  may  use  in  the  humble  home  in 
which  ignorance  of  the  mother  or  lack  of  ability  render 
impossible  the  making  of  the  more  complicated  mixture. 

One  takes  1  quart  of  buttermilk  and  1  quart  of  water, 
mixes  them  well,  lets  them  boil  a  few  minutes,  and  al¬ 
lows  them  to  stand  for  half  an  hour  or  more.  During 
this  period  the  casein  curd  settles  to  the  bottom  and 
the  clear  whey  water  mixture  rises  to  the  top.  You  see 
now,  by  the  addition  of  water  we  have  diluted  the  whey 
one-half.  Without  disturbing  the  casein  curd  lying  be¬ 
low,  we  pour  off  into  another  jar  as  much  of  this 
whey  as  possible.  In  this  way  we  have  separated  curd 
from  whey.  Remember,  in  this  mixture  we  have  boiled 
the  milk.  In  the  original  technique  we  used  the  milk 
raw.  If  we  had  boiled  the  milk  in  the  original  technique 
the  curds  would  have  been  so  fine  that  we  could  not 
have  separated  them  from  the  whey,  the  curds  being  able 
to  pass  during  the  filtration  through  the  meshes  of  the 
muslin  hag.  To  the  casein  curd  we  add  4  ounces  of 
boiled  cream.  This  is  done  because  in  the  original  mix¬ 
ture  during  the  precipitation  of  the  casein  considerable 
fat  was  ensnared  in  its  meshes,  the  fat  content  of  the 
albumin  milk  being  2  to  3  per  cent.  Accordingly,  we 
add  cream  to  this  mixture.  We  then  add  the  usual  3 
per  cent  per  quart  of  dextrimaltose.  Hot  having  dextri- 
maltose,  we  can  use  foods  of  somewhat  similar  nature, 
such  as  Mellin’s  Food  or  Horlick’s  Malt  food,  hut  not 
malted  milk.  Our  mixture  now  contains  high  protein, 
a  certain  amount  of  fat,  a  certain  amount  of  carbohy¬ 
drate  in  a  non-fermentahle  form,  and  to  add  salts 


93 


we  fill  up  to  a  total  of  one  quart  with  the  original  water 
whey  mixture  that  we  have  in  our  second  jar.  You  see 
in  this  process  we  have  reduced  the  whey  to  one-half 
strength.  In  cases  where  the  child  does  not  take  albu¬ 
min  milk  very  well,  it  can  be  sweetened  with  a  little 
saccharine.  A  large  nipple  should  be  used,  as  the  curds 
may  stick  in  a  smaller  one. 

And  now,  gentlemen,  before  concluding,  let  me  call 
your  attention  to  a  most  fascinating  study,  one  to  which 
this  treatment  with  albumin  milk  has  directed  us. 


At  A  the  weight  curve  has  straightened  out,  the  de¬ 
structive  process  has  ceased,  the  battle  has  been  won,  the 
child  is  getting  the  total  prescribed  amount  of  albumin 
milk ;  but  he  is  not  gaining.  We  have  pushed  up  the  al¬ 
bumin  milk  to  the  total  quantity,  namely,  3  ounces 
for  each  pound  of  body  weight,  and  the  weight  curve 
is  stationary.  Here  a  very  interesting  study  commences. 
Our  first  idea  that  sugar  alone  was  dangerous  and  harm¬ 
ful  makes  us  very  careful  about  increasing  the  carbo¬ 
hydrate.  More  with  a  feeling  of  conducting  an  ex¬ 
periment  than  of  aiding  the  baby,  we  increase  the  carbo¬ 
hydrate  to  5  per  cent.  In  some  cases  the  weight  curve 
makes  a  sharp  ascent  and  the  child  starts  to  gain.  In 
some  cases  the  weight  curve  remains  stationary.  After 
a  few.  days,  in  the  latter  case,  we  cautiously  feel  our 
way  agin  and  increase  to  7  per  cent.  Again  the  curve 
may  take  a  sharp  rise  and  the  improvement  continue, 
or  it  may  remain  absolutely  horizontal.  Again,  but  with 
extreme  care  and  caution,  we  increase  to  9  per  cent,  and 
almost  invariably  with  9  per  cent  each  child  will  start  to 
gain.  With  7  per  cent  or  9  per  cent  the  stools  may  be¬ 
come  dyspeptic,  but  employing  albumin  milk  we  may 


94 


overlook  them.  If  we  had  previously,  instead  of  in¬ 
creasing  to  7  or  9  per  cent,  added  1  to  2  per  cent  starch, 
we  might  have  produced  this  gain  in  weight  a  little  more 
quickly. 

This  most  interesting  clinical  study  gives  an  insight 
into  some  of  the  processes  that  are  taking  place  in  the 
child’s  body.  It  shows  us  that  this  child  needs  more  car¬ 
bohydrate  to  make  him  thrive  than  does  a  normal  child ; 
and  when  we  stop  to  think,  this  does  not  seem  so  un¬ 
reasonable,  because  this  child  is  so  handicapped  that  he 
probably  needs  more  energy  to  carry  him  along  than 
does  the  healthy  baby.  Now  we  see  our  problem.  We 
must  convey  food  to  this  child’s  tissues.  In  a  few  cases 
the  deficiency  is  one  of  protein  and  mineral  matter.  In 
a  majority  of  cases,  however,  high  carbohydrate  must 
also  be  conveyed.  We  have  before  us  the  problem  of 
sending  high  carbohydrate  into  the  baby’s  body;  of  get¬ 
ting  it  through  the  intestinal  wall  before  the  hungering 
bacteria  lying  in  wait  for  it  in  the  intestine  can  fer¬ 
ment  it  into  the  irritating  acid  products;  without  its 
carrying  the  patient  to  death  with  a  picture  of  intoxica¬ 
tion  before  it  can  reach  the  body  cells  craving  it.  This 
problem  albumin  milk  has  solved  in  a  mysterious,  unex¬ 
plainable  way.  It  was  never  put  together  for  this  pur¬ 
pose,  but  it  is  just  so  effective,  nevertheless.  If  we  would 
feed  a  child  with  decomposition  a  concentrated  milk 
mixture,  containing  high  carbohydrates,  the  child  would 
rapidly  develop  the  severest  intoxication.  With  albu¬ 
min  milk  we  can  feed  this  carbohydrate  with  relatively 
slight  danger  of  intestinal  complication. 

How  albumin  milk  causes  this  is  unknown.  We  have 
much  to  learn,  and  perhaps  some  one  will  explain  it  to 
us;  hut  it  is  a  fact,  nevertheless,  that  albumin  milk 
offers  to  us  the  vehicle  for  introducing  carbohydrate 
into  the  baby’s  system. 

The  treatment  with  albumin  milk  should  last  four  to 
six  weeks.  After  this  the  baby  can  he  put  at  once  upon 
an  ordinary  milk  mixture,  and  for  a  few  days  the  stools 
will  he  a  little  loose.  These  can  be  absolutely  disre¬ 
garded.  If  the  baby  has  been  fed  breast  milk,  during 
the  latter  part  of  the  treatment  the  use  of  small  quanti¬ 
ties  of  buttermilk,  up  to  one-third  or  one-half  the  total 
amount,  will  he  of  value.  Buttermilk  contains  high  pro- 


95 


tein  and  salts,  the  very  elements  in  which  breast  milk  is 
somewhat  deficient — deficient  not  for  the  normal  baby, 
but  deficient  for  a  badly  nourished  baby  who  has  to 
make  up  marked  past  losses. 

Having  mastered  these  processes,  we  are  now  in  a 
position  to  treat  decomposition  in  an  older  child. 
Always  hold  before  you  the  picture  of  this  technique 
with  albumin  milk.  In  the  older  child  the  period  of 
hunger,  if  diarrhea  is  present,  must  also  be  short,  and 
then  we  must  start  to  feed.  How  shall  we  make  up 
our  food?  First,  we  must  reduce  our  whey  as  much  as 
possible,  the  whey  being  the  element  that  seems  to  aid 
fermentation  and  the  formation  of  irritating  acids  in 
the  intestines.  This  means  that  we  can  either  remove 
the  milk  entirely  from  the  diet  or,  preferably,  dilute  it 
to  one-third  or  one-half  strength.  To  offer  the  child 
foods  which  will  tend  to  alkalinize  the  bowel  and  over¬ 
come  fermentative  processes,  we  feed  high  protein, 
namely,  scraped  meat,  eggs,  cottage  cheese,  or  even  the 
ordinary  curds  of  milk.  Custards  are  taken  well  by 
children  and  provide  an  easy  method  of  feeding  eggs. 
To  supply  carbohydrate  in  a  form  not  easily  ferment¬ 
able,  we  use  cereals,  such  as  corn  starch,  farina,  cream 
of  wheat,  arrowroot  and  well  boiled  rice.  We  would  not 
offer  oatmeal,  because  in  some  cases  this  seems  to  fer¬ 
ment  easily.  Other  nonfermenting  carbohydrates  are 
mashed  Irish  potatoes  and  the  doubly  baked  bread, 
known  usually  under  the  name  “Zwieback.”  Here,  now, 
we  have  a  combination  high  in  protein,  low  in  whey, 
containing  nonfermenting  carbohydrates,  low  only  in 
salts.  These  we  supply  by  offering  vegetables — ground 
through  a  very  fine  sieve — in  the  form  of  purees; 
broths  and  soups.  We  can  supply  a  mixture  high  in 
protein  and  in  salts  by  offering  a  small  quantity  of  but¬ 
termilk;  but  remember  that  the  butermilk  has  all  the 
whey  elements  of  the  milk  in  concentrated  form,  hence 
tends  to  aid  fermentation,  and  therefore  should  be  used 
in  tiny  quantities  and  handled  very  carefully. 

Remember,  gentlemen,  that  the  technique  we  use, 
however,  must  he  identical  to  that  employed  with  a 
little  baby.  The  hunger  periods  are  short,  the  quantity 
of  food  offered  at  first  rather  small,  gradually  increased, 
and  first,  and  above  everything  else,  the  guide  to  the 


96 


quantity  of  food  must  be  the  weight  curve  rather  than 
the  condition  of  the  stools. 

The  general  treatment  must  be  that  of  intoxication, 
laying  particular  emphasis  upon  the  protection  of  the 
child  from  all  dangerous  external  influences.  The  child 
must  be  well  cared  for,  protected  from  infections,  and, 
above  all  things,  guarded  from  extremes  of  heat  and 
cold. 

Our  hour  is  now  up.  I  have  tried  to  impress  upon 
you  the  great  importance  of  looking  upon  these  chil¬ 
dren  as  children  in  whom  entire  nutrition  is  changed. 
In  treating  such  a  baby  under  no  circumstances  let  the 
condition  of  the  stools  control  you  in  your  treatment. 
The  stools  are  only  a  symptom  of  the  condition  of  the 
gastro-intestinal  tract.  The  gastro-intestinal  tract  is 
simply  a  means  for  you  to  introduce  proper  elements 
of  food  to  the  baby.  If  you  decide  that  a  child  needs 
carbohydrate,  then  you  must  give  it.  Even  though  the 
digestive  tract  rebel,  even  though  diarrheal  stools  point 
to  fermentation,  don’t  lose  your  courage,  provided  the 
weight  curve  does  not  begin  to  sink.  In  the  latter  case, 
under  no  circumstances  totally  withdraw  the  carbohy¬ 
drate.  Humor  the  digestive  tract.  Change  your  food 
combination.  Give  your  carbohydrate  in  the  combina¬ 
tions  in  which  it  will  be  relatively  harmless — such  as 
breast  milk  or  albumin  milk — but  don’t  give  up  your 
principles.  With  a  little  compromise,  a  little  shifting 
of  technique,  a  wise  general  can  make  the  digestive 
tract  his  obedient  servant.  Never  under  any  circum¬ 
stances  let  it  become  your  master. 


LECTURE  VII 


PARENTERAL  AND  ENTERAL  INFECTIONS 
AS  FACTORS  IN  THE  CAUSATION  OF  “DIS¬ 
TURBANCES  OF  NUTRITION” 

Gentlemen,  we  now  have  finished  the  original  group 
of  disturbances  of  nutrition  as  Finkelstein  classified 
them.  You  remember  that  pathology,  bacteriology,  and 
etiology  have  failed  us,  and  in  our  present  state  clinical 
classification  is  probably  the  safest.  Do  not  for  a 
moment  think  that  the  last  word  has  been  said.  We 
are  learning  more  every  day.  Hew  factors  are  being 
added,  old  ideas  changed;  but  if  we  keep  the  clinical 
picture  constantly  before  us  we  shall  probably  not  go 
far  astray.  To  show  you  how  the  clinical  viewpoint  is 
constantly  guiding  us,  let  me  remind  you  of  the  modifi¬ 
cations  that  clinical  studies  made  upon  Czerny’s  idea 
of  “Milk  Injury.”  You  remember  that  bedside  observa¬ 
tion  added  the  new  factors  of  improper  care,  nursing, 
post-infection,  and  insufficient  sugar.  In  the  same  way, 
this  morning  I  wish  to  show  you  what  careful  clinical 
observation  has  done  toward  increasing  our  knowledge 
of  dyspepsia. 

The  original  viewpoint  of  Finkelstein  was  that  all 
cases  of  dyspepsia  were  due  to  sugar.  Later  this  was 
modified  to  sugar  and  whey.  For  a  moment  he  was 
side-tracked,  concentrating  too  exclusively  on  the  one 
symptom — the  acid  watery  stool;  but  clinical  observa¬ 
tion  and  thought  saved  the  day.  Let  us  illustrate : 

1.  In  his  institution  ten  babies  lie  in  each  ward.  Fre¬ 
quently  it  was  noticed  that  after  thriving  for  three  or 
four  weeks  every  baby  would  develop  a  mild  diarrhea. 
Had  we  focused  our  attention  too  exclusively  upon  the 
stools  we  probably  should  have  observed  a  few  curds  of 
fat,  a  little  mucus,  an  acid  reaction,  and  we  would 
have  said,  “Too  much  fat,”  or  “Too  much  sugar,”  or 
“Too  much  something  else,”  and  changed  the  inoffen¬ 
sive  baby’s  diet.  As  a  matter  of  fact,  by  keeping  the 
broader  picture  before  us,  inquiring  into  every  cause 
that  could  be  concerned,  we  learned  that  the  day  pre- 

7 


98 


ceding  the  disturbance  there  had  been  a  change  of 
nurses  in  the  ward.  This  observation  was  repeated 
frequently.  Almost  invariably  when  a  new  nurse  took 
up  her  duties  the  children  temporarily  became  ill.  Why 
a  change  of  nurses  should  cause  such  a  reaction  I  don’t 
know.  As  I  have  said  so  often,  “This  is  clinical  obser¬ 
vation.”  Perhaps  the  secret  lies  in  psychic  or  nervous 
influences.  At  any  rate,  it  was  perfectly  independent 
of  food. 

2.  Observations  have  shown  that  heat  is  an  impor¬ 
tant  factor.  This  stimulated  the  very  excellent  re¬ 
search  of  McClure  and  Sauer  at  the  Children’s  Me¬ 
morial  Hospital  of  our  city.  In  very  interesting  experi¬ 
ments  they  showed  that  retained  heat  is  more  important 
than  is  the  general  temperature.  A  baby  lightly  clothed 
on  a  very  hot  day  is  less  likely  to  become  dyspeptic 
than  is  an  overclothed  baby  during  milder  weather. 

3.  Keeping  the  broad  clinical  conception  of  “Dis¬ 
turbance  of  Nutrition”  before  their  eyes,  Pinkelstein 
and  his  assistants  made  the  following  observations  of 
unparalleled  importance :  A  new  baby  would  enter  the 
ward.  In  a  day  or  two  every  child  in  the  ward  would 
vomit  and  have  watery,  green,  mucus  stools.  Clinical 
pictures  varied  from  dyspepsia  to  intoxication  or  to 
decomposition.  Had  we  studied  the  stools  exclusively, 
we  should  undoubtedly  have  said,  “This  child  has  re¬ 
ceived  too  much  fat ;  this  one  too  much  sugar ;  this 
child  too  much  protein” ;  but  keeping  a  broader  con¬ 
ception  before  our  eyes,  trying  to  consider  every  factor 
possible,  we  learned  that  the  secret  of  the  matter  was 
simply  this :  The  food  upon  which  the  baby  had  previ¬ 
ously  been  thriving  had,  of  course,  absolutely  nothing 
to  do  with  it.  The  new  baby  had  a  little  cough  or  cold, 
a  little  nasopharyngitis  and  grippe,  or  if  it  were  a 
little  girl,  a  cystitis.  During  the  following  days  every 
child  in  the  ward  started  to  cough  and  to  sneeze,  and, 
following  this  infection ,  began  to  react  with  diarrheal 
bowel  movements.  This  observation  was  made  so  fre¬ 
quently  that  the  men  in  that  institution  and  in  many 
others  that  I  visited  came  to  believe  that  these  second¬ 
ary  diarrheas,  secondary  to  little  infections,  were  of  as 
great  or  even  greater  importance  than  the  primary  food 
disturbances.  To  these  infections  they  gave  the  name 
“Parenteral  Infections,”  signifying  by  that,  infectious 


99 


in  some  part  of  the  body  other  than  the  intestinal  tract. 
Gentlemen,  under  no  circumstances  forget  Parenteral 
infections.  They  constitute  a  large  part  of  the  diar¬ 
rheal  cases  which  you  meet  in  your  children’s  practice. 

Are  you  beginning  to  understand,  gentlemen,  how 
the  clinical  classification  of  Finkelstein  is  helping  us 
in  our  study?  I  do  not  for  a  moment  consider  it  a 
finished  affair,  hut  I  do  consider  it  a  most  valuable 
outline,  by  which  we  may  direct  further  observations. 

Parenteral  infections  are  of  such  tremendous  impor¬ 
tance,  I  want  to  talk  about  them  for  just  a  moment. 
How  a  cough  or  a  cold  causes  a  diarrhea  we  do  not 
know.  Such  is  purely  bedside  observation;  but  human 
nature  seeks  explanations,  and  for  that  reason  the  fol¬ 
lowing  picture  may  partially  satisfy  you.  Understand, 
however,  it  is  subject  to  great  modification  and  change. 

As  in  the  primary  food  disturbance  the  whey  of 
cow’s  milk  seems  to  injure  the  intestine  in  some  way 
and  to  allow  the  bacteria  which  are  normally  present 
in  the  large  intestine  to  flourish  in  the  upper  tract,  so 
in  these  parenteral  infections,  as  the  stools  are  typically 
of  the  “fermentative”  type,  must  we  also  have  an 
agency  stimulating  bacterial  growth  in  the  small  intes¬ 
tine.  How  can  a  parenteral  infection  increase  intes¬ 
tinal  fermentation?  Two  ways  become  apparent. 

1.  Finkelstein’s  assistants  have  shown  that  during 
the  progress  of  these  infections  the  qualities  of  the 
digestive  juices  are  changed.  They  are  decreased  both 
in  amount  and  in  activity.  As  a  result  of  such  changes 
two  influences  may  be  exerted : 

(a)  Undigested  food  and  sugar  will  proceed  lower 
than  usual  down  the  intestinal  tract. 

(b)  The  bacteria  of  the  large  intestine  may  come  up 
abnormally  high. 

2.  The  products  of  the  bacterial  action  in  the  nose 
and  throat  may  functionally  injure  the  intestinal  cells, 
and  impair  their  faculties  of  keeping  the  upper  intes¬ 
tine  sterile. 

In  this  way,  gentlemen,  you  see  conditions  in  the 
small  intestine  are  those  predisposing  to  a  disturbance 
of  nutrition.  In  this  case,  however,  is  the  effect  pro¬ 
duced  not  by  the  concentrated  whey  of  cow’s  milk,  but 
by  influences  perfectly  independent  of  the  food,  namely, 
the  products  of  the  parenteral  infection.  In  either 


100 


case,  the  presence  of  hungering  bacteria  in  the  small 
intestine  must  warn  us  that  feeding  fermentable  sugar 
will  lead  to  the  production  of  irritating  acids  and  the 
resulting  diarrhea.  The  disturbance  arising  from  the 
latter,  to  distinguish  from  a  primary  disturbance  in¬ 
duced  by  the  concentrated  whey  of  cow’s  milk,  we  may 
call  a  secondary  disturbance  of  nutrition. 

Just  as  we  have  learned  in  all  other  conditions,  the 
clinical  picture  is  greatly  influenced  by  the  factors  of 
age  (the  younger  the  child  the  severer  the  reaction), 
constitution,  nursing  and  care,  heat,  and,  above  all 
things,  food.  The  babies  fed  on  mixtures  very  high 
in  carbohydrate  and  whey  give  the  severest  symptoms. 

DIAGNOSIS 

The  diagnosis  of  such  a  disturbance  is  relatively 
easy. 

1.  The  history  shows  the  child  has  had  a  little  grippe 
or  febrile  disturbance  followed  by  the  diarrhea.  The 
mother  calls  you  for  the  intestinal  condition,  com¬ 
pletely  ignoring  the  fundamental  factor.  The  history 
showing  that  the  diarrhea  followed  the  cold  practically 
makes  the  diagnosis  for  you. 

2.  Food  withdrawal  for  twenty-four  hours  causes  a 
great  improvement  in  the  intestinal  condition  and  any 
resulting  disturbance  of  nutrition,  but  does  not  influ¬ 
ence  the  temperature.  The  following  day,  if  the  tem¬ 
perature  is  still  elevated,  you  make  a  careful  examina¬ 
tion  of  the  patient,  and  frequently  you  will  find  a 
pneumonia  or  an  otitis  or  a  cystitis  that  had  not  been 
evident  upon  the  first  examination. 

TEEATMENT 

The  treatment  divides  itself  into  that  of  the  primary 
cause  and  that  of  the  secondary  nutritional  disturbance. 

The  primary  infection  is,  of  course,  to  be  treated 
depending  upon  its  nature. 

The  secondary  disturbance  of  nutrition  is  to  be 
treated  upon  the  lines  we  have  already  laid  out,  purely 
and  simply  upon  the  nature  of  the  weight  curve.  If 
the  curve  rises  continuously,  as  is  usually  the  case  in 
the  healthy  breast-fed  baby,  a  steady  gain  being  noted 
each  day  in  spite  of  abnormal  intestinal  movements, 


101 


leave  that  baby  alone.  Don’t,  under  any  circumstances, 
change  the  food.  Just  see  the  picture!  Under  the  in¬ 
fluence  of  the  parenteral  infection  a  little  fermentation 
has  been  induced  in  the  intestine,  but  there  has  been 
no  nutritional  reaction  whatsoever.  The  effect  is  purely 
and  simply  local  and  intestinal  and  needs  no  more  food 
treatment  than  does  the  irritated  nose  in  a  coryza.  We 
do  not  even  have  the  picture  of  a  dyspepsia. 


The  second  type  of  reaction,  the  type  which  appears 
most  frequently  in  the  somewhat  undernourished  breast 
baby  or  in  the  fairly  well  nourished  bottle  baby,  is 
illustrated  by  the  accompanying  curve.  At  A  the  child 
gets  a  parenteral  infection.  The  accompanying  fer¬ 
mentation  has  become  severe  enough  to  produce  a  mild 


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dyspepsia.  The  slight  change  in  the  weight  curve 
shows  that  the  baby’s  nutrition  is  beginning  to  suffer. 
Shall  we  change  the  diet  in  this  case?  Leave  the  baby 


102 


alone.  Again  see  the  picture !  The  fault  was  not  pri¬ 
marily  with  our  food.  The  injury  lay  in  the  mild  in¬ 
fection  of  the  nose  and  throat  or  of  the  bladder.  A 
mild  secondary  disturbance  of  nutrition  has  arisen,  hut 
if  we  simply  wait  for  a  few  days  the  cough  and  cold 
will  disappear,  and  now  that  the  injuring  factor  is 
gone  the  intestine  will  correct  itself;  and  at  B  the 
weight  curve  will  start  to  ascend  and  the  diarrhea 
disappears. 

In  these  two  instances  treat  the  mother  as  you  will, 
hut  unless  he  begins  to  lose  weight  don’t  treat  the  baby. 
Let  him  take  as  much  food  as  he  will.  He  usually 
drinks  less  than  his  normal  amount,  and  so  spontane¬ 
ously  prevents  the  occurrence  of  the  secondary  disturb¬ 
ance. 


Fundamentally  different  is  a  third  type  of  reaction. 
This  occurs  in  the  babies  fed  on  one-sided  high  carbo¬ 
hydrate  mixtures.  The  baby  fed  with  condensed  milk  „ 
or  only  barley  gruel,  the  baby  with  the  masked  type  of 
decomposition  of  which  we  spoke  last  week,  shows  a 
sharp  and  severe  reaction.  With  the  onset  of  the  infec¬ 
tion  diarrhea  commences.  The  stools ,  however,  may 
not  vary  markedly  from  those  of  the  other  children. 
How  we  would  be  misled  by  focusing  too  exclusively 
upon  them !  But  the  child  reacts  with  a  marked  dis¬ 
turbance  of  nutrition  varying  in  type  from  a  mild  dys¬ 
pepsia  to  the  severest  intoxication  or  decomposition. 


103 


In  these  cases  forget  the  primary  factor.  The  mother 
may  think  the  baby  is  very  sick  from  his  cough  and 
cold,  but  you  know  that  death  is  going  to  occur  not 
from  the  mild  infection,  but  from  the  severe  secondary 
disturbance  of  nutrition.  In  these  cases,  first  and  fore¬ 
most  the  latter  must  receive  your  immediate  attention, 
and  you  must  handle  it  according  to  the  principles  laid 
out  in  the  previous  lectures,  depending  upon  the  nature 
of  the  nutritional  disturbance. 

Two  symptoms  arising  in  the  course  of  a  parenteral 
infection  may  need  treatment : 

1.  Vomiting. — If  the  vomiting  be  due  to  a  primary 
food  disturbance,  the  child  will  recover  upon  removal 
of  the  primary  cause,  namely,  the  food.  If,  however, 
the  condition  arises  from  a  parenteral  infection,  change 
of  food  will  have  no  effect,  and  unless  we  stop  the  vom¬ 
iting  we  may  meet  with  trouble.  In  these  cases,  gentle 
stomach  washing  is  of  value,  as  are  also  mildly  anes¬ 
thetic  drugs,  such  as  novocain  in  doses  of  l-60th  of  a 
grain  before  each  meal. 

2.  Anorexia. — If  the  loss  of  appetite  is  due  to  food, 
removal  of  the  cause  will  cure  the  condition.  If  the 
cause  of  anorexia,  however,  is  the  parenteral  infection, 
change  of  food  will  have  no  influence.  It  is  in  these 
cases  that  physicians  may  make  such  fatal  errors.  One 
often  hears  the  expression,  “If  the  baby  won’t  eat,  we 
will  starve  him  to  it.”  No  more  serious  mistake  can  be 
made  than  this.  The  cause  of  the  baby’s  loss  of  appe¬ 
tite  is  not  the  food,  but  is  the  product  of  the  parenteral 
infection,  and  you  may  starve  him  and  starve  him,  but 
his  appetite  will  not  return.  What  you  will  accomplish, 
however,  by  introducing  the  factor  of  hunger  is  to 
throw  the  baby  into  the  state  of  decomposition.  Many 
of  the  deaths  occurring  during  mild  infections  are  due 
not  to  this  primary  cause,  but  to  the  factor  of  decom¬ 
position,  developing  from  the  associated  anorexia.  Gen¬ 
tlemen,  the  baby  must  have  food.  If  he  takes  it  no 
other  way,  you  may  use  a  stomach  tube.  I  don’t  mean, 
now,  that  you  must  get  a  pump  and  pump  gallons  into 
his  stomach,  but  you  must  introduce  small  quantities, 
enough  to  keep  him  alive,  and  of  such  proportions  as 
to  avoid  the  dangers  of  a  secondary  dyspepsia  or  intoxi¬ 
cation. 


104 


The  factors  of  heat,  of  food,  of  parenteral  infection, 
and  of  care  are  frequently  all  concerned  in  the  produc¬ 
tion  of  dyspepsias  and  intoxications.  In  recognition 
of  this,  Finkelstein  suggests  classifying  them  into 
groups,  as  follows : 

I.  Purely  alimentary  or  food  type. 

II.  Mixed  type  (in  which  all  influences  are  con¬ 
cerned). 

Gentlemen,  we  have  now  finished  the  “Disturbances 
of  Nutrition.”  I  want  to  take  you  far  away  for  a 
moment  to  view  an  entirely  different  group  of  diseases. 
While  the  success  of  this  high  protein,  low  whey,  non- 
fermentable  carbohydrate  treatment  was  being  attested 
by  the  consensus  of  opinion  of  the  whole  world,  while 
in  the  Finkelstein  clinic  a  great  international  assem¬ 
blage  of  men  had  collected — men  from  America,  Eng¬ 
land,  Austria,  Russia,  Japan,  Bulgaria,  Roumania, 
Switzerland,  Portugal,  and  other  countries — all  testify¬ 
ing  to  the  great  influence  of  these  teachings,  a  com¬ 
munication  came  from  A.  I.  Kendall  of  the  Boston 
Floating  Hospital  saying  that  the  treatment  of  severe 
diarrhea  was  to  be  found  in  low  protein  and  high  car¬ 
bohydrate.  Could  anything  be  more  tantalizing,  more 
aggravating !  Just  at  the  moment  when  we  thought 
that  the  problem  of  diarrhea  in  children  was  forever 
solved,  when  we  thought  that  the  infallible  remedy  for 


105 


all  diarrhea  was  high  protein,  low  whey,  nonferment- 
able  carbohydrate,  we  must  read  that  the  proper  treat¬ 
ment  was  low  protein,  high  carbohydrate,  and  carbo¬ 
hydrate  in  a  fermentable  form,  such  as  lactose.  The 
first  inclination  was  to  do  as  we  always  do  when  some 
one  disagrees  with  us,  to  question  the  writer’s  sanity. 
Careful  study  of  the  publication,  however,  showed  that 
Kendall  was  speaking  of  a  group  of  diseases  entirely 
different  from  those  we  were  studying.  His  work  had 
to  do  with  the  true  infectious  diarrheas,  those  due  to 
specific  micro-organisms;  the  type  of  case  we  were  not 
seeing.  The  communication  was  so  interesting  that  I 
resolved  upon  my  return  to  this  country  to  try  to  meet 
Kendall  and  get  his  viewpoint.  To  my  very  great 
pleasure,  I  learned  that  he  had  been  called  to  take 
charge  of  the  department  of  Bacteriology  at  North¬ 
western  University  Medical  School,  the  institution  with 
which  I  was  to  be  connected.  Through  the  agency  of 
Dr.  I.  A.  Abt,  I  had  the  pleasure  of  meeting  Kendall 
and  of  having  many  heated  debates  with  him.  He, 
with  the  true  interest  of  the  bacteriologist,  was  con¬ 
cerned  mainly  with  the  deadly  infectious  diarrheas.  I 
was  interested  chiefly  in  the  question  of  nutrition.  To 
settle  the  point  as  regards  the  nature  of  the  material  in 
Chicago,  we  made  a  little  study  during  the  summer  of 
1914. 

Dr.  Alexander  Day,  one  of  Kendall’s  associates,  who 
had  been  with  him  during  the  work  on  the  Boston 
Floating  Hospital,  examined  from  the  standpoint  of 
the  bacteriologist  all  cases  of  severe  diarrhea  in  our 
hospital  wards.  He  made  careful  cultures  of  all  the 
stools,  while  I  studied  the  cases  from  the  standpoint 
of  “nutritional  disturbance,”  looking  at  them  from  the 
clinical  aspect  and  noting  their  weight  and  food  reac¬ 
tions.  Our  results  showed  that  during  this  summer  in 
our  hospital  wards  in  Chicago  one  or  two  cases  of  diar¬ 
rhea  showed  the  presence  of  the  gas  bacillus  in  the 
stools,  two  cases  showed  the  typical  reactions  to  food  as 
are  obtained  in  the  primary  food  disturbances,  and  the 
remainder  of  the  cases  were  those  associated  with 
coughs  and  colds,  the  so-called  parenteral  infections. 
During  a  study  made  the  following  year,  we  found  two 
cases  of  severe  dysentery  sent  to  the  hospital  from  out 
of  town,  one  to  Dr.  Abt,  one  to  Dr.  Julius  Hess,  cases 


106 


entirely  different  in  nature  from  our  ordinary  diarrheal 
cases;  babies  showing  the  symptoms  typical  in  every 
respect  to  those  of  dysentery  infection,  which  Kendall 
had  noted  in  Boston.  Dr.  Day  discovered  the  true 
organism  of  dysentery  in  these  cases. 

Why  is  it  that  in  Boston  infectious  diarrheas  prevail, 
in  Chicago  the  nutritional  disturbances?  The  failure 
to  discover  infectious  diarrheas  in  Chicago  could  not 
have  been  due  to  a  different  technique,  as  the  investi¬ 
gations  were  conducted  by  the  same  men.  We  must 
regard  these  results  as  conclusive.  Why  this  difference 
prevails  I  do  not  know.  Day  and  I  offered  the  explana¬ 
tion  at  that  time  that  in  the  sense  of  Brenneman  the 
difference  may  be  due  to  the  fact  that  in  the  East  raw 
milk  had  been  used,  in  Chicago  boiled  milk.  Isn’t  it 
reasonable  to  assume  that  in  the  East,  while  raw  milk 
was  used  the  deadly  infectious  diarrheas  prevailed,  that 
in  the  Middle  West,  where  these  organisms  with  one 
Stroke  had  been  removed  by  boiling,  the  nutritional  dis¬ 
turbances  only  are  seen? 

Gentlemen,  in  this  part  of  the  country  probably 
many  of  your  patients  use  raw  milk.  When  you  are 
called  to  see  a  baby  with  diarrhea,  you  will  be  at  once 
confronted  with  the  problem,  “Is  this  an  infectious 
diarrhea  or  is  it  one  of  the  nutritional  type?”  As  you 
will  learn  in  a  moment,  to  distinguish  between  these 
two  is  of  fundamental  importance.  We  have  several 
means. 

a.  The  history .  The  acute  infectious  diarrhea  usu¬ 
ally  starts  suddenly  in  a  previously  well  baby,  and  pros¬ 
trates  him  at  once.  The  nutritional  disturbance  comes 
about  more  gradually.  We  frequently  can  get  a  history 
of  improper  feeding,  of  previous  nutritional  disturb¬ 
ance,  of  parenteral  infection.  It  is  more  gradually 
progressive. 

h.  The  stools.  These  are  of  considerable  aid  to  us 
in  our  diagnosis.  In  the  infectious  diarrhea,  particu¬ 
larly  dysentery,  the  stools  are  small,  consisting  chiefly 
of  blood-stained  mucus.  They  contain  barely  any  solid 
material,  and  by  use  of  the  microscope  we  may  discover 
pus.  The  reaction  of  the  stool  in  dysentery  is  alkaline. 
The  stools  in  the  nutritional  disturbance  are  green, 
usually  acid  and  watery.  They  contain  increased  solid 
material,  some  mucus,  but  rarely  blood  or  pus  unless 
the  case  has  long  been  neglected. 


107 


c.  The  reaction  to  food  is  of  some  value.  If,  after 
twenty-four  hours  of  tea,  the  temperature  continues 
high,  the  weight  curve  sinks,  the  diarrhea  continues 
with  small,  bloody  mucus  stools,  then  some  other  factor 
must  be  at  hand,  other  than  food.  If  careful  physical 
examination  rules  out  parenteral  infection,  such  as 
pneumonia  or  sepsis,  the  diagnosis,  by  exclusion,  will 
probably  be  definite  enteral  infection. 

Gentlemen,  what  I  have  to  tell  you  about  the  treat¬ 
ment  of  true  infectious  diarrheas  will  be  disappointing. 
All  that  I  can  do  is  to  expose  our  ignorance  and,  per¬ 
haps,  by  this  exposure  stimulate  us  to  increased  efforts 
for  progress.  The  treatment  of  infectious  diarrhea 
depends  just  as  absolutely  upon  a  definite  bacteriologic 
diagnosis  as  does  the  treatment  of  pneumococcus  ton- 
silitis  depend  upon  throat  culture  to  distinguish  it 
from  diphtheria.  How  to  treat  cases  of  infectious  diar¬ 
rhea  in  this  part  of  the  country  I  do  not  know,  for  I 
have  absolutely  no  idea  what  types  of  infections  you 
meet.  If  it  is  a  gas  bacillus,  one  food  must  be  given; 
if  it  is  a  dysentery  bacillus,  radically  the  opposite  treat¬ 
ment  must  be  instituted.  Bacteriologic  methods  of 
diagnosis  are  difficult.  A  trained  bacteriologist  is  neces¬ 
sary.  An  agglutination  reaction  in  dysentery,  such  as 
the  Widal  in  typhoid,  can  he  of  service.  All  that  I 
can  do,  gentlemen,  is  to  urge  you,  in  connection  with 
your  medical  society,  to  cooperate  with  the  State  Board 
of  Health  or  with  the  State  University  in  attempting 
to  discover  the  types  of  infections  that  exist  here. 

I  won’t  bother  you  even  with  the  technique  for  dysen¬ 
tery.  The  gas  bacillus,  however,  can  be  detected  by  a 
relatively  simple  test ;  hut  this,  too,  requires  some 
training. 

Get  a  sterile  specimen  of  the  baby’s  stool.  This  can 
he  obtained  by  taking  a  sterile  glass  tubing  with 
rounded  ends,  about  the  thickness  of  a  lead  pencil,  and 
inserting  it  into  the  rectum  as  one  would  a  thermom¬ 
eter.  Usually  a  little  fecal  material  is  obtained  in  the 
tube.  If  the  rectum  is  empty,  repeat  this  in  an  hour. 
Then  inoculate  a  small  quantity  of  the  stool,  about  the 
size  of'  a  oea,  into  a  test  tube  of  milk.  This  test  tube 
is  heated  to  180  degrees  for  half  an  hour.  During  this 
process  all  bacteria  are  killed  except  the  spores  forming 
organisms.  These  resist  heat  and,  when  the  milk  is 
incubated  at  body  temperature  for  eighteen  hours,  grow 


108 


rapidly.  As  the  gas  bacillus  splits  sugar  into  acetic 
and  butyric  acids,  a  characteristic  test  would  give  the 
odor  of  rancid  butter.  Secondly,  the  acid  causes  the 
casein  to  coagulate.  This  is  precipitated  in  large  curds, 
but,  due  to  the  growth  of  the  gas  bacillus,  it  has  the 
appearance  of  being  completely  “shot  to  pieces.” 
Lastly,  the  microscope  shows  the  large  Gram  positive 
bacillus. 

The  treatment  for  gas  bacillus  infection,  according 
to  Kendall,  is  based  upon  the  observations  that  the  gas 
bacillus  grows  well  in  sugar  and  does  not  grow  well 
with  high  protein  or  lactic  acid.  In  such  an  infection, 
therefore,  the  treatment  is  buttermilk.  The  albumin 
milk,  of  which  we  have  spoken,  due  to  its  high  protein, 
low  carbohydrate,  and  lactic  acid,  would  also  be  an 
ideal  treatment.  Kendall  has  made  the  interesting  sug¬ 
gestion  that  perhaps  some  of  the  cases  that  Finkelstein 
treated  so  successfully  with  albumin  milk  were  really 
those  of  gas  bacillus  infection.  This  is  a  very  interest¬ 
ing  criticism,  but  I  don’t  believe  will  bold  true  in  many 
instances. 

The  treatment  for  true  infectious  dysentery  is  based 
upon  entirely  different  principles.  Here  one  has  great 
ragged  ulcers  in  the  intestine.  In  these  the  dysentery 
organisms  live  and  produce  toxins,  just  as  do  the  diph¬ 
theria  bacilli  from  their  location  in  the  throat.  Death 
occurs  in  dysentery  largely  from  toxemia.  You  see, 
then,  gentlemen,  how  hopeless  drug  therapy  is  in  dysen¬ 
tery.  We  may  give  calomel.  We  may  give  medication 
to  flush  out  the  intestine.  In  small  quantities  they 
may  do  no  harm.  To  me,  however,  the  giving  of  cathar¬ 
tics  in  such  cases  seems  to  he  like  the  mechanical  tear¬ 
ing  out  of  the  membrane  of  diphtheria  with  a  forceps. 
What  folly !  If  our  sole  therapy  in  diphtheria  is  physi¬ 
cal  injury,  we  kill  the  baby.  Our  treatment  lies  in 
antitoxin ;  and  so  is  it  with  dysentery.  Our  ultimate 
success  must  lie  in  the  administration  of  antitoxin,  if 
we  can  give  it  in  time. 

In  speaking:  of  calomel,  gentlemen,  I  understand  that 
this  drug  is  used  very  considerably  down  here,  and  that 
you  place  great  faith  in  it.  It  may  be  very  efficient. 
I  do  not  know,  because  I  do  not  know  the  types  of 
infection  with  which  you  are  dealing.  Maybe  you  have 
organisms  to  which  calomel  is  deadly.  That  remains 


109 


to  be  seen.  The  wisest,  after  all,  is  to  try  to  establish 
means  for  obtaining  definite  diagnoses. 

The  general  treatment  of  dysentery  must  be  that  of 
all  infectious  disease.  Keep  up  the  fluids,  provide 
proper  nursing  and  care,  stimulate  if  necessary.  Opium 
may  be  of  great  value.  In  the  nutritional  diarrheas 
opium,  by  disguising  the  symptoms,  might  lull  us  into 
an  insecure,  dangerous  self-satisfaction.  In  dysentery, 
however,  where  the  bacillus  and  not  the  food  is  the 
factor,  we  disguise  no  symptoms  with  opium,  but  quiet 
our  little  patient  and  relieve  the  pain  and  tenesmus. 
Give  as  much  as  you  can  with  safety.  As  regards  medi¬ 
cation,  quinine-tannate  in  doses  of  3  to  5  grains  three 
times  a  day  is  highly  recommended ;  but,  as  I  have  said 
so  frequently,  do  not  put  too  much  confidence  in  drugs. 

The  dietetic  treatment  is  radically  different  from 
that  of  nutritional  disturbance  and  from  gas  bacillus 
infection.  Theobald  Smith,  the  great  American  bac¬ 
teriologist,  years  ago  observed  that  if  the  diphtheria 
bacillus  be  grown  on  carbohydrate  media  it  will  not 
produce  toxin,  but  if  grown  on  protein  it  produces  the 
typical  toxin  of  diphtheria.  Kendall,  working  from 
this  viewpoint,  experimented  with  the  dysentery  organ¬ 
ism  and  found  that  if  it  be  grown  on  carbohydrate  no 
poison  is  produced,  while  if  grown  on  protein  the  deadly 
dysentery  toxin  results.  This  explains,  then,  why  he 
advocated  a  high  carbohydrate  feeding  and  reported 
good  results  in  his  cases  of  dysentery.  He  wished  to 
get  carbohydrate  to  the  dysentery  organisms  growing 
in  the  intestine  and  thus  prevent  the  formation  of 
toxin.  From  this  standpoint  two  forms  of  dietetic 
treatment  can  be  employed : 

1.  Breast  Milk. — Breast  milk  with  its  low  protein 
and  high  carbohydrate  would  make  an  ideal  food  such 
as  Kendall  demands  and  at  the  same  time  would  not 
endanger  the  child  by  the  causation  of  a  disturbance 
of  nutrition. 

2.  The  Frank  Treatment. — This  has  been  the  most 
successful  in  the  realm  of  artificial  feeding.  I  give  it 
to  you  as  it  is  recommended. 

(a)  '  Tea  for  twenty-four  hours,  except  in  cases  of 
decomposition. 

(b)  Start  on  the  second  day  with  five  feedings,  each 
of  which  is  composed  of  2  ounces  of  whey  and  2  ounces 
of  gruel. 


110 


(c)  Gradually  increase  by  the  fourth  or  fifth  day  to 
five  feedings  of  2%  ounces  each. 

( d )  On  the  fifth  to  the  eighth  day  gradually  replace 
in  teaspoonful  doses  the  whey  by  milk.  Gentlemen,  see 
how  important  the  diagnosis  is.  Here,  we  have  kept 
our  patient  on  a  mixture  of  sugar,  salts,  and  barely  any 
protein  for  five  days.  This  would  have  been  the  worst 
thing  possible  in  cases  of  nutritional  disturbance  or  gas 
bacillus  infection. 

( e )  On  the  twelfth  to  the  fourteenth  day  perfectly 
independent  of  the  stools  the  little  patient  must  be  get¬ 
ting  13  to  14  ounces  of  milk,  13  to  14  ounces  of  gruel, 
and  6  to  7  ounces  of  broth.  He  may  also  receive  a  little 
cereal,  as  rice,  farina,  cream  of  wheat,  etc.,  and,  if 
over  one  year  of  age,  a  little  meat. 

This,  then,  is  the  most  successful  up-to-date  treat¬ 
ment  for  infection  with  true  dysentery.  How  compli¬ 
cated  how  long,  often  how  unavailing!  Why  not  with 
one  stroke  save  yourselves  and  your  patients  all  this 
wearisome  treatment  and  danger,  practice  a  little 
prophylaxis,  and  boil  the  milk? 

We  have  now  finished  the  subject  of  nutritional  dis¬ 
ease.  We  have  given  you  the  viewpoints  which  have 
been  developed  in  the  great  European  clinics  and 
adopted  in  the  Middle  West.  You  may  frequently  have 
wondered  at  the  hours  given  to  nutritional  conditions, 
and  may  be  disappointed  in  the  few  words  given  to  in¬ 
fection.  Time  prevents  a  thorough  consideration  of 
everything.  I  laid  most  emphasis  upon  the  former  with 
the  idea  of  preparing  you  for  the  future.  I  believe  that 
if  you  boil  your  milk,  disturbance  of  nutrition  will  be 
the  type  preeminent,  the  picture  which  will  become 
more  and  more  apparent  in  your  practice. 

We  have  spoken  little  of  the  American  ideas.  We 
have  done  this  because  we  feared  that  we  might  be 
misinterpreted,  that  we  were  attempting  to  criticise.  I 
cannot  conscientiously  leave  the  subject  without  for  a 
moment  giving  you  the  opinions  of  our  Eastern  friends. 
But  don’t  for  a  moment  misunderstand  me.  So  much 
difference  of  opinion,  so  much  unpleasantness,  has 
arisen  by  the  discussion  of  different  things,  that  I  am 
perfectly  willing  to  admit  that  every  man  who  makes 
a  classification  is  right,  and  that  he  classifies  things 
according  to  his  own  material. 


Ill 


Holt,  for  instance,  speaks  of  feeding  and  disturbances 
of  nutrition  in  one  chapter.  In  disturbances  of  nutri¬ 
tion  be  considers  only  inanition,  malnutrition,  and 
marasmus.  In  discussing  these,  he  does  not  give  us 
sharp  clinical  pictures,  but  describes  conditions  which 
to  us  suggest  different  stages  of  the  group  that  we  call 
decomposition.  His  diarrheal  diseases  he  classifies 
under  those  of  the  gastro-intestinal  tract,  and  considers 
that  the  great  majority  of  them  are  of  the  type  associ¬ 
ated  with  definite  pathological  lesions  in  the  intestine. 
To  him  diarrheas  do  not  belong  to  the  group  of  dis¬ 
turbances  of  nutrition. 

Morse  and  Talbot  devote  most  of  their  time  to  the 
technique  of  feeding.  The  disturbances,  they  classify 
as  “Diseases  of  the  gastro-intestinal  canal,”  and  under 
this  group  they  place  pylorospasm,  pyloricstenosis, 
nervous  disturbance,  constipation,  digestive  disturb¬ 
ances,  etc.  This  suggests  the  Vienna  idea — the  laying 
of  fundamental  importance  upon  the  gastro-intestinal 
tract,  but  considering  the  disturbance  in  the  modern 
light  of  physiology  rather  than  of  pathology.  Under 
the  digestive  disturbances  they  speak  of  disturbances 
from  too  much  food.  They  speak  of  disturbances  from 
excess  of  one  element  of  the  food,  such  as  from  fat, 
from  carbohydrate,  from  protein,  and  from  salts,  and 
they  speak  of  indigestion  with  fermentation. 

It  is  not  for  me  to  criticise  any  of  these  views.  Each 
one  is  undoubtedly  correct,  depending  upon  location 
and  material.  From  the  viewpoint  of  Chicago,  we  pre¬ 
fer  the  clinical  classification  because  we  believe  the 
broad  conceptions  in  it  will  aid  us  in  further  study. 
We  like  the  term,  “Disturbance  of  Nutrition, ”  rather 
than  that  of  gastro-intestinal  disease,  because  we  be¬ 
lieve  this  conception  prevents  our  focusing  too  closely 
upon  the  stool — even  though  the  primary  causative  fac¬ 
tor  lay  in  the  intestinal  canal — because  we  believe  the 
baby’s  general  condition  is  far  more  important  than 
that  of  his  gastro-intestinal  tract,  because  our  whole 
plan  of  feeding  and  therapy  depends  not  upon  the  stool, 
but  upon  the  weight  curve,  and  we  believe  that  this 
latter  gives  us  the  best  index  of  the  baby’s  general  con¬ 
dition  :  of  the  combined  influences  exerted  by  “food,” 
by  “ intestine  ”  and  by  “demands  of  the  body.” 


c 


112 


Just  one  word  more.  A  recent  communication  of 
1916  from  Dr.  Louis  W.  Hill  of  Boston,  who  is  con¬ 
ducting  so  successfully  the  sections  in  the  East,  divides 
diarrheas  into  three  groups,  namely: 

1.  The  Infectious  Type. 

2.  The  Nervous  Type. 

3.  The  Fermentative  Type. 

Regarding  the  latter,  he  goes  into  some  length  show¬ 
ing  the  antagonistic  effects  of  protein  and  carbohydrate 
and  laying  emphasis  upon  carbohydrate  fermentation 
in  the  production  of  the  irritating  lower  fatty  acids. 
He  recognizes  carbohydrate  as  a  primary  factor  even 
in  some  cases  where  much  fat  is  excreted.  This  is,  of 
course,  typically  Finkelstein.  Hill  still  considers  these 
diarrheas  as  local  intestinal  affairs,  but  shows  evidence 
of  the  “nutritional”  viewpoint  in  recognizing  clothing 
and  heat  as  factors. 

For  the  first  time  now  the  East  is  beginning  to  lay 
great  importance  upon  the  fermentative  factor  in  the 
causation  of  diarrhea.  Why  it  has  not  noticed  this 
before  I  do  not  know. 

Powers  of  observation  do  not  depend  upon  geographi¬ 
cal  location.  There  must  be  some  deeper  factor,  some 
truer  explanation.  One  thought  constantly  repeats  it¬ 
self  to  my  mind :  Cannot  the  whole  difference  be  ex¬ 
plained  upon  this  basis  of  boiled  milk?  Isn’t  it  pos¬ 
sible  that  the  East  is  in  the  stage  of  evolution,  that 
during  the  period  of  raw  milk  the  pictures  of  the  spec¬ 
tacular,  dramatic,  deadly  infectious  diarrheas  pre¬ 
vailed?  Small  wonder  that  little  attention  was  paid 
to  the  milder,  more  easily  controlled  disturbances  of 
nutrition.  But  now,  as  I  understand  it,  boiled  milk 
is  coming  to  its  own.  Isn’t  it  possible  that  for  the  first 
time  the  gradual  waning  of  infectious  diarrhea  reveals 
the  slow  rise  of  disturbance  of  nutrition?  Hill’s  classi¬ 
fication,  a  radically  different  one  from  that  advanced 
by  Morse  and  Talbot  a  few  years  ago,  would  suggest 
this  stage  of  evolution.  We  shall  eagerly  await  new 
developments.  Will  this  conception  reach  sufficient 
growth  to  alter  the  Eastern  method  of  feeding,  as  it 
has  ours? 


LECTURE  VIII 


ARTIFICIAL  FEEDING  OF  THE  NORMAL 

INFANT 

Gentlemen,  the  system  of  artificial  feeding  developed 
in  the  Middle  West  is  based  upon  the  studies  that  have 
been  pointed  out  to  you.  One  does  not  start  with  a  pre¬ 
conceived  idea  as  regards  a  definite  and  exact  formula, 
but  by  knowledge  of  the  various  disturbances  that  may 
arise  from  improper  combinations  one  attempts  simply 
to  suggest  mixtures  which  will  not  lead  to  future  diffi¬ 
culty.  The  fundamental  requisite  in  infant  feeding  is  a 
little  good  common  sense. 

Before  going  into  these  methods  it  might  be  well  to 
rid  ourselves  of  a  few  conceits.  If  one  takes  a  young 
animal  and  allows  him  to  hunger,  that  animal,  never¬ 
theless,  continues  to  grow.  He  will  not  gain  in  weight, 
but  he  will  grow  in  size.  So  is  it  with  the  baby.  Don’t 
for  a  moment  think  that  you  are  responsible  for  the 
baby’s  growing.  You  are  simply  offering  him  bricks 
and  mortar  ‘n  the  way  of  food,  but  certainly  you  are 
not  entirely  responsible  for  his  growth.  Don’t  take 
yourselves  too  seriously!  You  are  an  outside  factor,  an 
external  influence — important,  it  is  true,  but  by  no 
means  the  sole  cause  of  the  baby’s  thriving. 

Remember  that  the  mother  does  not  feed  the  baby 
at  the  breast.  The  baby  feeds  itself.  The  mother  does 
not  start  with  the  preconceived  idea  of  how  much — of 
how  many  ounces — she  is  going  to  give  the  baby.  She 
simply  puts  the  baby  to  the  breast,  the  child  takes  what 
it  wants,  and  when  satisfied  stops. 

Gentlemen,  get  the  Idea  out  of  your  head  that  you 
are  going  to  feed  the  baby.  Leave  a  little  of  the  re¬ 
sponsibility  to  him ! 

Remember,  by  all  means  that  the  baby  is  human. 
Think  of  yourselves,  for  instance.  Your  appetite  varies 
depending  upon  the  weather,  upon  your  mood,  upon 
the  nature  of  the  food.  On  a  hot  day  you  eat  less  than 
on  a  cold  day.  You  do  not  eat  the  same  amount  each 
lay.  Some  of  you  are  vegetarians;  some  of  you  are 

8 


114 


large  meat  eaters;  some  of  you  eat  combinations  of 
both.  So  is  it  with  the  baby.  Just  remember  that  he 
is  human,  that  his  appetite  will  vary,  that  no  two  babies 
are  alike,  that  it  is  only  fair  to  meet  him  half-way  and 
to  make  a  reasonable  attempt  to  adjust  our  mixtures  to 
meet  his  individual  demands,  rather  than  to  expect  all 
concessions  from  him. 

Remember  that  when  we  eat  our  fundamental  worry 
is,  “Will  this  food  agree  with  me?”  If  we  can  take 
our  meal  without  causing  digestive  trouble,  if  we  get 
the  food  past  the  intestinal  tract  into  the  body,  then 
our  troubles  largely  are  over.  The  body  uses  what  it 
needs  and  throws  out  the  excess.  Why  should  the  baby 
be  different?  Any  food  which  can  pass  the  intestinal 
tract  into  the  body,  any  food  which  contains  enough 
bricks,  and  stones,  and  mortar,  will  provide  for  the 
baby’s  growth.  The  child  retains  in  its  body  what  it 
needs  and  casts  out  what  it  does  not  need,  whether  the 
food  be  breast  milk  or  cow’s  milk. 

Thus  you  see  any  system  of  feeding  which  enables 
the  food  to  pass  the  intestinal  tract  into  the  body  is 
relatively  successful.  There  is  no  right  way  nor  no 
wrong  way  of  feeding;  all  methods  are  right.  Our 
main  concern  is  simplicity.  We  must  answer  the  body 
requirements  and  therefore  employ  the  intestine  simply 
as  our  agent  in  introducing  foodstuffs  for  this  purpose. 

How  often  shall  we  feed  a  child?  The  great  pedia¬ 
trician,  Czerny,  helped  us  by  suggesting  the  four-hour 
feeding  system — five  feedings  in  twenty-four  hours, 
viz. :  6  :00  o’clock — 10  :00 — 2  :00 — 6  :00 — 10  :00 ;  and 

none  from  10  :00  p.  m.  to  6  :00  a.  m.  In  Chicago,  Gru- 
lee  is  an  ardent  advocate  of  Czerny,  and  according  to 
Grulee  every  baby,  whether  it  be  a  five-pound  prema¬ 
ture  or  a  fine  healthy  ten-pound  new-born,  should  re¬ 
ceive  feedings  no  oftener  than  once  every  four  hours. 
He  has  demonstrated  the  success  of  this  method  re¬ 
peatedly.  Personally,  from  my  own  experience,  I  be¬ 
lieve  some  of  the  smaller  children  and  some  of  the 
children  under  four  to  six  weeks  of  age  do  better  with 
the  three-hour  schedule.  Four  hours  seem  rather  long 
for  them  to  wait.  For  this  reason  I  recommend  to 
those  under  four  to  six  weeks  of  age  seven  feedings, 
viz. :  6  :00  o’clock — 9  :00 — 12  :00 — 3  :00 — 6  :00 — 9  :00, 

and  once  during  the  night.  Undoubtedly,  though,  the 


115 


majority  of  these  would  do  equally  well  on  the  four 
hours  schedule. 

The  number  of  feedings  offered  varies  somewhat  with 
locality.  I  believe  in  the  East  they  feed  more  fre¬ 
quently  than  we  do.  A  simple  little  experiment  which 
we  made  in  the  Finkelstein  Clinic  might  explain  these 
differences.  Babies  in  some  wards  we  fed  according 
to  the  percentage  method;  babies  in  others  we  fed  ac¬ 
cording  to  the  methods  I  am  about  to  teach  you.  All 
were  given  five  feedings  in  twenty-four  hours.  The 
percentage  babies  vomited  more  than  did  the  others. 
As  the  percentage  method  frequently  requires  more  fat 
than  does  ours,  we  reasoned  that  this  vomiting  was  due 
probably  to  the  fat,  i.  e.,  to  the  larger  amount  of  the 
lower  fatty  acids  in  cow’s  milk  fat.  Just  by  empiricism 
we  found  that  we  could  stop  these  percentage  babies 
from  vomiting  by  feeding  smaller  quantities  more  fre¬ 
quently.  So  in  a  short  time  all  the  percentage  babies 
had  several  more  feedings  a  day  than  did  the  others, 
and  thrived  beautifully.  I  believe  in  a  way  this  ex¬ 
plains  the  differences  in  feeding  schedule  in  the  two 
localities.  The  percentage  system  frequently  requires 
higher  fat  than  does  ours. 

How  much  shall  he  offer  our  babies?  As  you  see, 
the  amount  offered  in  each  bottle  must  depend  upon 
the  number  of  feedings;  the  greater  the  frequency  the 
less  the  individual  quantity.  Again,  don’t  try  to  follow 
any  hard  and  fast  rule.  Some  babies  take  more;  some 
babies  take  less.  In  a  general  way  the  first  time  we  see 
a  child  we  can  guide  ourselves  as  follows : 

a.  From  the  second  to  the  fourth  or  sixth  week  a 
child  will  drink  in  twenty-four  hours  a  total  of  about 
20  ounces. 

b.  From  the  fourth  to  sixth  week,  to  about  the  third 
month,  he  drinks  approximately  a  total  of  25  ounces. 

c.  From  about  the*  middle  of  the  third  month  he  will 
drink  a  quart. 

This  is  no  rigid  routine.  Try  the  baby  on  this 
amount  and  see  how  he  reacts.  Take  the  mother  into 
your  confidence — many  mothers  have  really  more  in¬ 
telligence  than  we  imagine;  ask  her  if  the  baby  seems 
hungry,  if  he  frets  directly  after  finishing  his  bottle,  if 
he  is  peevish  before  the  three  hours  are  passed.  If  so, 
increase  the  quantity.  On  the  other  hand,  if  the  mother 


116 


tells  you  “The  baby  is  perfectly  satisfied ;  does  not  even 
finish  the  bottle,”  or,  perhaps,  “vomits  after  taking  the 
bottle,”  we  simply  suggest  that  instead  of  allowing  the 
baby  twenty  minutes  for  each  feeding,  she  reduce  the 
time  to  fifteen.  After  a  week  or  so  you  will  find  the 
amount  can  again  be  increased. 

What  shall  we  offer  the  baby?  Almost  any  system 
of  feeding  has  its  ardent  advocate.  The  possibilities 
of  the  normal  child’s  intestinal  tract  are  immense.  The 
normal  baby  takes  almost  anything  and  thrives.  There¬ 
fore,  it’s  easy  to  understand  how  many  different  sys¬ 
tems  of  infant  feeding  have  arisen,  each  with  its  enthu¬ 
siastic  adherents.  The  French,  for  instance,  have  at 
times  recommended  full  milk.  Many  children  do  well 
on  this;  some  don’t.  The  old  German  pediatrician, 
Biedert  (he  was  the  one  who  first  described  the  casein 
curds  in  the  baby’s  stool),  recommended  the  dilution 
of  milk  to  lower  the  protein.  This  weakened  the  milk, 
of  course,  and  so,  to  make  up  for  the  loss  of  strength, 
he  added  cream  and  sugar.  The  resulting  mixture  was 
somewhat  like  a  percentage  mixture.  Some  children 
thrived  beautifully  on  these  combinations;  some  did 
not. 

A  further  advance  was  made  by  Heubner  in  bring¬ 
ing  calories  to  our  notice.  He  it  was  who  reminded  us 
that  a  baby  should  have  45  calories  per  pound  body 
weight.  This  system  is  not  ideal,  as  you  can  readily 
see.  A  child  may  have  the  proper  number  of  calories 
in  his  bottle,  but  these  may  be  only  fat  or  sugar,  and 
will  not  satisfy  the  demands  of  his  body.  Again,  vari¬ 
ous  studies  show  that  prematures  require  more  calories 
than  do  normal  babies.  Lastly,  later  studies  show  that 
mysterious  invisible  substances,  called  vitamines,  play 
important  roles  in  growth.  These,  of  course,  cannot  be 
measured  by  caloric  value. 

A  very  splendid  igenious  improvement  in  our 
methods  was  that  offered  by  the  old  percentage  system. 
We  might  say  that  the  idea  concerned  in  this  was  per¬ 
fect,  viz.,  the  attempt  to  make  cow’s  milk  resemble 
breast  milk.  The  unfortunate  feature  in  this  system 
was — as  we  told  you  in  our  first  lecture — that  such  a 
modification  is  impossible.  We  cannot  make  cow’s  milk 
resemble  breast  milk.  Again,  these  mixtures  were  made 
upon  the  supposition  that  disturbances  arise  from  un- 


117 


digested  casein.  Such  we  believe,  when  milk  is  boiled, 
to  be  very  rare.  Casein  may,  of  course,  produce  dam¬ 
age  in  the  sense  of  the  Vienna  pediatrician,  Ham¬ 
burger,  when  it  passes  in  undigested  form  through  the 
intestinal  wall  and  circulates  in  the  body  as  foreign, 
protein;  but  this  complication  in  a  normal  intestine 
we  believe  to  be  uncommon.  Another  objection  to  the 
old  percentage  system,  according  to  our  viewpoint,  was 
that  it  suggested  in  advance  what  a  baby  was  to  receive, 
perfectly  independent  of  the  baby.  Our  method  con¬ 
siders  the  baby  first,  foremost,  above  everything  else, 
and  then  the  mixture.  Lastly,  the  old  percentage  sys¬ 
tem  offered  mixtures  of  high  carbohydrate  and  fat  in 
the  medium  of  cow’s  milk  whey.  In  breast  milk  whey, 
high  carbohydrate  and  fat  are  harmless;  in  the  mys¬ 
terious  whey  of  cow’s  milk  these  combinations,  as  we 
learned  in  our  lecture  on  dyspepsia  and  intoxication, 
seem  to  favor  trouble. 

Recently  the  percentage  system  has  been  modified. 
We  now  read  that  primarily  it  is  not  intended  to  make 
milk  resemble  breast  milk,  but  only  in  a  general  way 
should  we  follow  the  principles  of  breast  milk,  and  that 
it  is  no  longer  a  definite  system  of  feeding,  but  simply 
a  means  of  making  up  mixtures  so  that  we  know  their 
content  exactly.  This,  we  think,  is  a  splendid  and  most 
excellent  step  forward.  Ludwig  F;  Meyer  once  said  to 
me,  “What  an  ideal  combination  would  result  if  one 
would  take  your  American  percentage  system  and  adapt 
it  to  some  of  these  principles  which  we  have  been  de¬ 
veloping!”  Gentlemen,  I  think  we  are  proceeding  in 
the  right  direction. 

The  Eastern  methods  are  those  attempting  to  avoid 
the  danger  of  protein  and  fat ;  our  methods,  of  avoiding 
whey  and  carbohydrate.  Perhaps  both  of  us  are  right ; 
perhaps  the  Eastern  men  see  true  disturbances  arising 
from  fat  because  they  use  higher  fat  in  their  mixtures ; 
perhaps  we  see  few  disturbances  from  fat  and  almost 
exclusively  those  from  carbohydrate  and  whey  because 
our  modifications  are  made  chiefly  with  carbohydrate. 

I  understand  that  Dr.  Hill,  who  is  conducting  the 
sections  in  the  eastern  part  of  this  State,  has  devised 
aome  simple  rules  for  making  accurate  modification  of 
milk.  Any  means  which  will  increase  the  exactness  of 
our  knowledge,  if  it  be  simple  enough  to  be  practicable, 
we  welcome  most  heartily. 


118 


OUR  METHOD  OF  FEEDING 


The  system  we  have  developed  from  these  great  Euro¬ 
pean  studies  is  prophylactic  from  the  start.  We  have 
learned  that  the  fault  does  not  lie  exclusively  with  one 
element  of  the  milk;  that  the  fault  depends  upon  im¬ 
proper  relations  of  the  different  elements.  Thus,  if  we 
give  sugar  in  concentrated  whey,  diarrhea  results;  if 
we  give  sugar  in  highly  diluted  whey,  the  chances  of 
resulting  disturbances  are  greatly  decreased.  If  we 
give  fat  in  combination  with  high  carbohydrate,  in  a 
medium  of  cow’s  milk,  we  frequently  shall  have  trouble. 
The  fat  may  be  involved  either  primarily  or  second¬ 
arily.  If,  however,  we  give  this  very  same  fat  in 
combination  with  albumin  milk,  viz.,  with  high  pro¬ 
tein,  low  whey,  and  nonfermentable  carbohydrate,  the 
fat  becomes  harmless.  Fat  in  an  acid  intestine  en¬ 
hances  diarrhea,  in  an  alkaline  intestine  enhances  con¬ 
stipation.  Therefore,  in  our  feeding  we  attempt  to 
dilute  all  elements  of  the  milk  and  to  have  only  one 
element  in  large  amount.  In  the  baby’s  intestine  high 
fat  and  high  sugar  in  cow’s  milk  are  not  agreeable 
companions.  Prophylaxis,  then,  is  our  motto,  and  we 
proceed  as  follows : 

1.  To  exclude  all  possibility  of  infectious  diarrhea, 
to  protect  our  baby  from  dysentery  and  other  virulent 
infections,  and  to  prevent  the  formation  of  tough  casein 
curds,  we  boil  the  milk. 

2.  To  prevent  in  any  way  the  accusation  that  we  are 
predisposing  to  scurvy,  we  add  at  the  end  of  the  first 
month  orange  juice  in  doses  of  a  teaspoon  each  day.  Dr. 
Alfred  Hess  of  Hew  York  has  shown  this  to  be  ex¬ 
tremely  important. 

3.  We  hear  the  following  picture  in  our  mind.  Gen¬ 
tlemen,  I  do  not  believe  you  will  find  this  scheme  given 
in  any  text  or  definitely  formulated  just  as  I  give  it, 
but  in  a  general  way  it  represents  our  point  of  view: 


Well  Baby 


Disturbed  Balanc 


I 


Dyspepsia 

Intoxication 


The  above  picture  shows  the  well  baby  included  in 
the  group  of  sick  babies,  and  suggests  that  this  very 
same  well  baby  can  be  made  to  assume  any  one  of  the 


119 


four  clinical  types.  The  factors  concerned  in  these 
changes  are  the  improper  usage  of  carbohydrate  and 
whey  and  the  improper  understanding  of  the  role  of 
fat  as  the  secondary  factor.  The  conditions  on  the 
right  develop  from  too  high  carbohydrate  in  whey;  the 
conditions  on  the  left  arise,  as  Czerny  would  have  first 
said,  from  too  much  fat ;  as  Finkelstein  would  say,  from 
too  little  sugar.  Of  course,  constitution,  infection,  etc., 
are  important  accessory  factors. 

What  is  the  purpose  of  this  scheme?  It  suggests 
that  our  attitude  in  feeding  must  be  identical  to  that, 
for  example,  in  typhoid  fever.  In  typhoid  we  don’t 
treat  the  disease;  we  simply  try  to  guide  and  to  steer 
our  patient  through  the  difficulties  that  lie  in  his  path; 
and  so  it  is  with  infant  feeding.  We  don’t  feed  the 
baby;  we  simply  guide  him.  We  try  to  avoid  the 
dangers  of  excessive  carbohydrate  on  the  one  hand  and 
of  insufficient  carbohydrate  on  the  other. 

4.  The  next  step  in  our  scheme  of  prophylaxis  re¬ 
quires  a  careful  history  and  physical  examination  of 
the  patient.  If  he  be  a  weak  child,  if  he  have  dys¬ 
pepsia,  if  he  have  a  parenteral  infection,  if  he  be  suf¬ 
fering  from  poor  care,  we  must  be  careful  as  to  order¬ 
ing  large  amounts  of  carbohydrate.  If  the  examination 
suggest  a  condition  of  disturbed  balance  or  if  the  child 
be  recovering  from  an  infection,  he  needs  increased 
carbohydrate.  Our  problem  in  the  latter  case  is  to  offer 
the  increased  carbohydrate  to  the  body  in  such  a  way 
as  not  to  endanger  the  intestine. 

How  shall  we  make  mixtures  to  avoid  intestinal  com¬ 
plication?  Gentlemen,  this  sounds  complicated,  but  it 
is  extremely  simple.  There  is  absolutely  nothing  to  it. 
You  may  banish  from  your  minds  any  worries  that  you 
may  have  regarding  the  difficulties  of  infant  feeding. 
It  is  the  simplest  branch  of  pediatrics !  Simplicity  is 
our  motto,  and,  indeed,  so  simple  is  our  method  that 
any  novice  may  use  it  successfully: 

(1)  To  avoid  the  occurrence  of  too  many  elements 
in  large  amounts,  we  dilute  the  milk. 

(2)  Up  to  about  the  first  four  weeks  we  use  one  part 
milk  and  two  parts  water. 

(3)  From  then  up  to  the  third  or  fourth  month  we 
use  one-half  milk  and  one-half  water. 

(4)  From  the  third  to  the  fourth  month  we  use  two- 
thirds  milk;  one-third  water. 


120 


(5)  Here  I  might  mention  the  teaching  of  Dr.  Julius 
Hess  of  the  University  of  Illinois.  In  discussing  feed¬ 
ing  with  his  students,  he  frequently  finds  it  very  ad¬ 
vantageous  to  follow  the  old  Budin  rule:  l1/}  ounces  of 
whole  milk  for  every  pound  of  the  baby’s  weight;  but 
I  believe  that  even  thi.s  rule,  though  very  convenienty 
is  scarcely  necessary. 

In  these  mixtures,  as  the  strength  of  our  milk  is 
weakened,  we  must  offer  additional  food,  and  preferably 
one  element  rather  than  two.  This  is  best  done  by 
adding  a  carbohydrate  in  a  nonfermentable  form,  such 
as  the  mixtures  of  dextrin  and  maltose.  These  are 
Mead’s  Dextri-Maltose,  Mellin’s  Food,  etc.  We  add 
these  carbohydrates  in  amounts  of  approximately  3 
per  cent  the  first  time  we  see  the  child,  and,  depending 
upon  the  reaction,  increase  gradually  to  5. 

At  six  months  we  may  start  slowly  with  a  soft  diet 
which  I  have  so  frequently  given  you,  and  then  our 
troubles  are  over. 

During  these  first  six  months  what  shall  be  our 
guide?  How  shall  we  know  that  the  baby  is  doing 
well  ?  Gentlemen,  under  all  circumstances,  let  the 
weight  curve  be  your  index.  If  the  baby  is  gaining  in 
weight  on  an  average  of  5-7  ounces  per  week,  and  at 
the  same  time  seems  clinically  well,  leave  him  alone. 
Ho  matter  though  his  stools  be  a  little  dyspeptic,  no 
matter  if  he  have  a  slight  colic  or  slight  diarrhea;  if 
he  is  gaining  in  weight,  leave  him  alone.  Your  main 
difficulty  will  he  in  treating  the  mother,  particularly 
the  mother  of  the  first  baby.  She  sits  at  the  baby’s 
bedside;  in  one  hand  she  clasps  “Mother  so  and  so’s 
guide  to  infant  feeding,  based  upon  forty  years  experi¬ 
ence.”  She  scans  each  stool  with  minute  accuracy, 
seizes  with  enthusiasm  upon  any  slight  abnormality 
such  as  a  tiny  curd  of  fat  or  a  little  mucus,  and  tells 
you  with  a  sort  of  gloomy  joy  that  the  food  is  not  agree¬ 
ing  with  her  baby.  Under  these  circumstances  treat 
the  mother  as  you  will.  Tell  her  that  the  condition  is 
normal;  that  mother  so  and  so’s  guide  book  is  old- 
fashioned.  Do  anything  you  wish ;  but  leave  the  haby 
alone. 

Only  in  one  condition  may  gain  of  weight  be  decep¬ 
tive.  This  is  when  a  baby  has  been  fed  condensed  milk, 
high  starch,  or  high  salt  mixtures.  In  these  cases  the 


121 


gain  of  weight  may  at  times  be  due  purely  to  a  water¬ 
logging  of  the  body  and  not  due  to  true  increase  in 
tissue  substance.  History  will  at  once  reveal  this  error, 
and,  knowing  the  danger  in  advance,  you  will  of  course 
not  prescribe  such  feeding. 

During  the  first  few  months  you  must  see  the  baby 
or  hear  from  the  mother  every  few  weeks,  and  you  will 
be  called  to  meet  several  indications: 

a.  After  a  week  or  so  the  baby  may  cease  to  gain  and 
the  weight  curve  become  straight.  The  stools  are  not 
over  two  or  three  per  day.  Under  these  conditions,  first 
consult  the  mother  and  ask  if  the  baby  is  hungry.  If 
the  baby  cries  after  his  bottle,  puts  his  fingers  in  his 
mouth  between  feedings,  frets  before  the  next  bottle, 
seizes  it  with  avidity,  and  drains  it  rapidly,  increase 
the  total  quantity  of  food;  or,  if  the  baby  is  getting  a 
sufficient  quantity,  increase  the  milk  by  a  few  ounces. 

b.  If  the  child  is  not  gaining,  does  not  seem  extremely 
hungry,  and  is  suffering  from  marked  constipation, 
then  it’s  perfectly  safe  to  increase  the  proportion  of 
carbohydrate  in  the  diet.  In  this  increase  we  have  a 
means  of  truly  winning  the  mother’s  affection.  If  our 
increase  is  in  nonfermentable  carbohydrate,  gain  in 
weight  may  result,  but  the  constipation  will  persist. 
If  we  increase  with  fermentable  carbohydrate,  such  as 
milk  sugar  or,  more  simply,  cane  sugar,  not  only  will 
the  gain  in  weight  result,  but  also  the  resulting  fer¬ 
mentation  will  correct  constipation.  So,  by  striking 
the  proper  balance  between  dextrin-maltose  on  the  one 
hand  and  fermentable  carbohydrate  on  the  other,  we 
have  a  means  by  which  we  regulate  absolutely  the  con¬ 
dition  of  the  intestine  and  by  which  we  bring  joy  to 
the  anxious  mother’s  heart. 

c.  If  the  weight  curve  straightens  out,  but  at  the 
same  time  the  stools  are  fermentative,  we  are  con¬ 
fronted  with  the  one  problem  that  may  arise  in  this 
system  of  feeding.  These  dyspeptic  stools  we  have 
learned  may  be  a  symptom  of  underfeeding  or  may  be 
a  symptom  of  a  true  beginning  dyspepsia.  Here  we 
are  aided  greatly  by  history  and  physical  examination. 
If  the  child  shows  definite  symptoms  of  hunger,  if 
questioning  shows  the  mother  of  her  own  accord  has 
not  made  some  change  in  her  milk  mixture,  and  ex¬ 
amination  shows  that  tho  child  loohs  well ,  then  it  is 


122 


safe  cautiously  to  increase  slightly  the  amount  of  food, 
noting  the  reaction.  In  such  a  case,  however,  one  would 
not  increase  the  proportion  of  carbohydrate,  but  simply 
would  increase  the  total  quantity,  not  changing  the 
relations  of  different  elements.  If,  on  the  other  hand, 
the  child  shows  a  tendency  to  avoid  food — these  little 
children  are  often  so  much  wiser  than  we;  if  exami¬ 
nation  shows  that  he  has  perhaps  a  very  slight  fever, 
that  he  does  not  look  quite  so  well,  that  he  has  rings 
under  his  eyes,  and,  above  all  things,  if  there  is  that 
mysterious  change  of  color  of  the  skin,  in  a  few  hours 
the  rosy  pink  becoming  an  ashen  gray,  we  know  that 
we  are  probably  dealing  with  a  case  of  beginning  dys¬ 
pepsia.  In  these  cases,  marked  increase  of  food  will 
make  the  disturbance  worse.  It  is  best  to  give  the  baby 
only  the  quantity  he  wishes  and  await  results. 

d.  If,  in  connection  with  the  fermentative  stool  and 
the  change  of  appearance  of  the  child,  the  weight  curve 
starts  to  drop,  then  we  are  dealing  with  a  case  of  dys¬ 
pepsia  or  beginning  intoxication  of  decomposition,  and 
treatment  must  be  instituted  accordingly. 


In  all  cases,  however,  by  watching  our  weight  curve, 
and  by  studying  our  little  patient  carefully,  we  can 
check  these  disturbances  before  they  originate,  and  the 
amount  of  severe  conditions  arising  will  be  very  few 
indeed. 

What  is  the  advantage  of  our  method  over  the  others  ? 
Perhaps  its  extreme  simplicity.  Any  method  used  by 
the  man  trained  in  its  application  will  be  successful. 
Our  method,  however,  we  believe  to  be  easiest  for  the 
untrained  man — the  man  who  has  not  had  time  to  work 
up  his  own  technique. 

As  an  example  of  this,  let  me  quote  my  experiences 
in  the  Chicago  Infant  Welfare  Society.  This  organiza¬ 
tion  was  founded  by  private  subscription  some  six  or 


123 


seven  years  ago.  Its  object  was  not  charity,  but  was 
education.  The  idea  was  to  reduce  infant  mortality, 
not  by  medical  treatment  but  by  prophylaxis;  not  by 
curing  the  sick  baby  but  by  keeping  the  well  baby  well. 
With  this  end  in  view,  one  station  was  organized  in  our 
poorer  districts.  A  physician  attended  twice  a  week. 
A  salaried  nurse  was  in  charge.  Mothers  were  urged 
to  bring  their  well  babies  for  advice  as  to  feeding,  and 
during  the  intervals  between  conferences  the  nurse  went 
into  the  home  and  gave  the  mothers  simple  instruction 
as  to  the  technique  to  be  employed  in  the  making  up  of 
mixtures.  Ho  medicine  was  given;  no  milk  supplied. 
The  mothers  could  buy  their  milk  where  and  from 
whom  they  chose.  At  the  station  they  got  nothing — 
but  advice. 

Gentlemen,  the  success  of  this  new  experiment  was 
astounding.  The  swarms  of  mothers  flocking  to  thi3 
first  station,  the  immediate  lowering  of  infant  mortal¬ 
ity,  were  all  the  evidence  necessary  to  show  that  this 
new  departure  was  a  brilliant  success.  The  organiza¬ 
tion  has  now  grown  in  the  last  few  years  from  the 
original  one  station  to  twenty-one.  The  numbers  of 
infants  seen  at  each  conference  average  about  thirty, 
but  often  run  up  to  fifty  of  an  afternoon.  Whenever 
one  of  these  stations  is  opened,  in  that  district  does 
infant  mortality  drop.  This  experience  was  in  a  way 
very  humiliating  to  me.  I  served  the  society  for 
several  years  in  the  capacity  of  assistant  medical  direc¬ 
tor.  During  that  time  I  had  ten  or  eleven  stations 
under  my  charge  and  visited  them  each  once  a  month. 
I  saw  many  men  for  the  first  time  come  to  take  charge 
of  these  stations ;  saw  these  men  instructed  in  the 
simple  methods  of  feeding  which  I  have  laid  out  for 
you,  and  saw  these  men  in  a  very  few  weeks  time  get 
just  as  successful  results  as  did  I  with  a  much  wider 
experience.  These  men  had  never  read  nor  probably 
had  ever  even  heard  of  Finkelstein  or  Czerny  or  Heub¬ 
ner  ;  but  the  results  they  accomplished  were  all  that  was 
necessary.  Nothing  speaks  more  for  the  simplicity  in 
our  method  of  feeding  than  does  the  success  of  our 
infant  welfare  society.  True  disturbances  of  nutrition 
rarely  arise.  The  children  become  simply  “feeders.” 

From  this  experience,  gentlemen,  one  impression  is 
growing  more  and  more  upon  me.  This  is  the  funda- 


124 


mental,  the  previously  unrecognized  but  the  indispen¬ 
sable  service  of  our  nurses.  We,  in  the  stations  or  in  the 
dispensaries,  see  the  baby  for  a  moment  and  write  out 
a  formula  for  a  milk  mixture;  the  nurse,  however,  gets 
into  the  home  and  meets  the  true  condition.  She  sees 
all  the  great  influences  which  are  at  work — the  acces¬ 
sory  aiding  influences,  the  influences  which  are  con¬ 
stantly  at  work  undermining  the  baby’s  constitution 
and  upsetting  our  plans.  She  instructs  the  mother  as 
to  the  proper  clothing  of  the  baby;  she  tells  the  mother 
that  on  a  warm  summer’s  day  it  is  unwise  to  wrap  the 
baby  up  in  thick  layers  of  clothing,  surround  him  with 
a  pillow,  place  him  near  the  kitchen  stove.  She  informs 
the  mother,  on  the  other  hand,  that  under  these  same 
conditions  it  is  unwise  to  put  the  baby  in  the  ice  box. 
She  informs  the  mother  about  the  dangers  of  flies,  and 
attempts  to  guide  the  mother  in  a  simple  way  to  protect 
the  child  from  these  pests.  She  shows  the  mother  how 
to  bathe  the  baby.  She  dwells  upon  the  importance  of 
regularity  of  feeding;  she  demonstrates  the  proper  care 
of  the  bottle  and  the  cleansing  of  the  rubber  nipple ;  she 
shows  the  mother  how  to  keep  the  milk  cool  by  placing 
the  bottle  in  a  tub  of  cool  water,  if  no  ice  box  is  avail¬ 
able.  In  short,  she  fulfills  the  indications  which 
Schlossman  so  pointedly  expressed  when  he  said,  “A 
good  nurse  can  always  overcome  the  mistakes  of  any 
poor  physician.” 

Gentlemen,  those  of  you  who  are  interested  in  infant 
feeding,  those  of  you  who  wish  wider  experience  in 
dealing  with  nurslings,  those  of  you  who  wish  to  do  an 
inestimable  amount  of  good  in  the  poorer  districts, 
should  attempt  to  establish  such  an  organization  as  an 
Tnfant  Welfare  Society;  and,  in  your  own  practice,  put 
into  execution  the  lessons  that  we  have  learned  from 
our  experience.  Where  you  have  not  one  of  these 
splendid  nurses  available,  be  yourselves  a  little  more 
the  nurse,  a  little  less  the  physician.  Make  the  mother 
clearly  understand  that  she  is  not  doing  her  duty  by 
simply  mixing  up  the  milk  in  the  proportions  which 
you  have  suggested,  but  that  she  must  fulfill  all  the 
other  requirements  which  are  so  essential  to  the  baby’s 
general  health,  and  without  which  any  system  of  feed¬ 
ing  will  fail.  If  you  only  will  lay  sufficient  emphasis 
upon  the  nursing  care  of  your  infants,  the  feeding  will 
almost  take  care  of  itself. 


125 


Have  we  solved  the  last  word  in  infant  feeding?  Is 
our  method  going  to  last?  I  do  not  think  so.  Hew 
advances  will  constantly  be  made — advances  which  we 
always  shall  be  ready  to  adopt,  no  matter  what  be  their 
source.  I  believe  firmly  that  we  have  mastered  the  art 
of  guiding  food  past  the  intestinal  tract  into  the  body, 
but  rather  than  rest  upon  our  laurels  we  must  arise  to 
attack  newer  and  more  intricate  nroblems — problems 
which  loom  ominously  before  us.  Are  our  combinations 
those  best  adapted  to  meet  the  demands  of  the  body ? 
In  years  to  come  we  may  learn  that  boiled  milk  has 
produced  some  hidden,  undiscovered  damage.  We  have 
learned  that  high  carbohydrate  fed  exclusively  or  in 
combination  with  high  salts  fills  the  tissues  with  water 
but  does  not  satisfy  their  hunger.  Some  evidence 
shows  that  children  fed  with  no  fat  in  the  diet  may  at 
times  possess  a  decreased  immunity  to  infection.  We 
may  learn  in  time  that  our  slight  reduction  of  fat,  that 
our  slight  relative  increase  of  carbohydrate,  though 
passing  the  intestine  easily  and  safely,  may  not  have 
been  a  combination  best  adapted  for  the  use  of  the  body 
tissues.  Only  years  of  study  and  observation  will 
answer  these  questions.  The  physiologist,  Friedenthal, 
has  recently  devised  a  mixture  in  which  the  salt  pro¬ 
portions  are  identical  to  those  of  breast  milk.  Normal 
amounts  of  fat  and  carbohydrate  may  be  given  in  this 
mixture  with  little  evidence  of  intestinal  disturbance. 
This  is  a  splendid  step  forward — a  means  of  introduc¬ 
ing  fat  and  carbohydrate  into  the  tissues  in  the  same 
proportions  as  they  exist  in  breast  milk,  and  with  no 
danger  to  the  intestinal  tract — but  is  as  yet  somewhat 
impracticable. 

Until  these  indications  can  be  met  practically  and 
simply,  until  we  can  introduce  to  the  tissues  foodstuffs 
in  the  same  proportions  as  they  exist  in  breast  milk 
without  in  any  way  impairing  digestive  and  assimila¬ 
tive  functions,  we  believe  that  our  method  of  feeding 
is  the  most  feasible.  It  is  easily  employed,  seems  to 
satisfy  the  mothers,  seems  to  provide  for  the  growth 
of  healthy,  thriving,  happy  babies,  who  look  ivell  and 
strong  and  appear  smiling  and  contented,  and,  first  and 
foremost,  it  answers  the  requirements  of  simplicity . 


LECTURE  IX 


BREAST  FEEDING 

Gentlemen,  we  shall  concern  ourselves  today  with  the 
breast-fed  infant.  I  have  neglected  the  subject  of 
breast  feeding  until  now  because  in  many  cases  must 
one  supplement  the  breast  with  the  bottle.  If  one  has 
mastered  the  art  of  prescribing  artificial  mixtures,  then 
difficulties  of  supplementary  feeding  will  be  very  slight 
indeed. 

It  is  not  necessary  to  emphasize  to  you  the  import¬ 
ance  of  breast  feeding.  All  of  you  know  that  breast 
milk  is  the  natural  food.  All  of  you  know  that  the 
breast-fed  infant  is  much  more  immune  to  infectious 
disease  than  is  the  artificially  fed.  All  of  you  know 
that  mortality  is  much  less  among  the  breast-fed  than 
among  the  bottle-fed  babies.  Whenever  there  is  any 
possibility  of  offering  the  baby  breast  milk,  by  all  means 
do  so. 

Contraindications  to  breast  feeding  are  becoming 
fewer  and  fewer.  Among  the  more  general : 

1.  Tuberculosis  of  the  mother  almost  unanimously 
is  agreed  a  distinct  contraindication  to  nursing. 

However,  against  this  practically  universally  ac¬ 
cepted  idea  some  voices  are  lifted.  Tubercle  bacilli 
have  never  definitely  been  demonstrated  in  the  human 
breast  milk.  Some  men  claim  if  the  mother  during 
nursing  will  protect  the  baby  from  her  coughing,  that 
tuberculosis  is  a  contraindication  only  from  her  own 
standpoint  and  not  from  that  of  the  child.  This  is, 
however,  the  opinion  of  a  few,  but  I  give  it  to  you  to 
show  how  even  against  this  most  orthodox  of  all  our 
contra-indications  objections  slowly  are  being  raised.  I 
believe,  though,  that  the  great  consensus  of  opinion 
makes  tuberculosis  of  the  mother  a  contraindication  to 
nursing,  not  only  from  her  own  standpoint,  but  also 
from  that  of  the  child. 

2.  Severe  constitutional  disease,  such  as  diabetes,  epi¬ 
lepsy,  and  malignancy,  of  course  are  contraindications. 

3.  As  regards  acute  infectious  diseases,  such  as  ty- 


127 


phoid,  scarlet  fever,  diphtheria,  etc.,  opinion,  particu¬ 
larly  in  the  European  clinics,  is  becoming  more  and 
more  tolerant.  The  new-born  has  considerable  immun¬ 
ity  to  infectious  disease.  Again,  pathogenic  bacteria 
have  never  been  demonstrated  as  transmitted  by  breast 
milk,  and  the  theoretical  objection  that  toxins  are  ex¬ 
creted  may  be  met  with  the  theoretical  answer  that  anti¬ 
toxins  also  will  pass  to  the  child.  Even  in  diphtheria, 
if  a  child  be  properly  immunized,  breast  feeding  is  per¬ 
mitted. 

These  are  the  opinions  of  many  of  the  leading  Euro¬ 
pean  men.  They  may  seem  rather  radical  to  you,  gen¬ 
tlemen.  I  give  them  to  you,  however,  to  emphasize  the 
importance  in  which  breast  feeding  is  held,  and  to  show 
that  most  contraindications  are  those  raised  in  consid¬ 
eration  of  the  mother  rather  than  the  infant.  Even 
in  erysipelas,  where  a  superficial  infection  of  the  breast 
makes  it  possible  that  organisms  may  be  found  in  the 
milk,  the  latter  may  be  drawn  off,  boiled,  and  then 
offered  to  the  baby. 

4.  Syphilis  is  an  indication  for  nursing  rather  than  a 
contraindication.  Whether  the  syphilitic  woman  be 
mother  of  an  apparently  well  baby  or  whether  an  en¬ 
tirely  well  woman  be  mother  of  a  synhilitic  baby,  in  all 
cases  should  we  insist  upon  breast  feeding,  for  in  both 
these  conditions  we  believe  that  mother  and  child  are 
alike  infected. 

As  regards  local  contraindications  from  the  stand¬ 
point  of  the  mother,  there  are  perhaps  two  to  be  con¬ 
sidered  : 

1.  Retracted  nipples  cause  a  great  deal  of  difficulty, 
cause  much  anxiety  to  the  mother,  and  add  great  diffi¬ 
culties  to  the  child.  In  many  cases,  however,  if  you 
practice  a  little  patience  these  difficulties  will  be  over¬ 
come.  Instead  of  surrendering  in  despair  to  the  mother, 
simply  tell  her,  “Yes,  it’s  going  to  be  hard  for  the  baby 
to  nurse ;  but  if  you  practice  patience  and  perseverance, 
frequently  after  a  week  or  two  the  child  will  learn  to 
take  the  breast.”  Patience  and  perseverance  are  the 
requisites  necessary,  and  after  a  week  or  two  of  con¬ 
scientious  work  the  mother  may  be  able  to  educate  her 
child  to  nurse  from  nipples  that  previously  seemed 
hopeless.  An  aid  in  this  treatment  is  drawing  out  the 
nipples  between  nursing  periods  by  the  use  of  a  breast 
pump. 


128 


2.  Erosions  and  fissures  of  the  nipples  are  extremely 
disagreeable  complications — ones  which  will  cause  you 
a  great  deal  of  anxiety  and  ones  which  by  the  pain  in¬ 
flicted  upon  the  mother  make  nursing  a  very  great 
burden  indeed.  The  variety  of  treatments  offered  for 
fissured  nipples  is  of  itself  sufficient  evidence  of  the  in¬ 
efficiency  of  any  particular  method.  Medicaments  sug¬ 
gested  are: 

(a)  The  use  of  a  little  cotton  swab  saturated  in  a 
one  to  two  per  cent  silver  nitrate  solution  laid  upon  the 
fissure  for  one  minute  once  during  the  day. 

( b )  The  following  prescription  is  one  quite  highly 
recommended.  Personally,  I  have  had  no  experience 
with  it  whatsoever,  but  I  give  it  to  you  upon  the  recom¬ 
mendation  of  foreign  writers: 

Silver  Nitrate  Gr.  XV 

Balsam  of  Peru  M  LXXV 

Lanolin 

Vaselin  AA  Oz.  Ill 

This  may  he  applied  frequently. 

A  very  valuable  point  in  treating  this  distressing 
complication  is  the  use  of  a  mild  local  anesthetic  oint¬ 
ment.  A  5  per  cent  salve  of  anesthesin  applied  to  the 
fissure  just  before  nursing  is  to  the  mother  a  very  great 
relief.  Anesthesin  is  not  poisonous  to  the  child,  and 
is  very  grateful  to  the  mother  on  account  of  the  relief 
of  the  severe  pain. 

(c)  In  treating  this  complication,  to  give  the  painful 
nipple  as  much  rest  as  possible,  longer  feeding  intervals 
should  be  employed.  Indeed,  one  might  substitute  a 
bottle  for  one  nursing.  Hiople  shields,  too,  are  of  value. 
The  very  best  of  these  is  a  large  one  made  of  pure  rub¬ 
ber  almost  covering  the  breast,  and  called  the  “Infanti- 
bus.”  It  is  an  imported  shield ;  so  I  doubt  whether  you 
can  get  it  now;  but  when  the  war  is  over  probably  you 
may  again  obtain  it,  and  it  is,  I  believe,  the  best  on  the 
market. 

Contraindications  from  the  standpoint  of  the  child 
are  not  many.  Cleft  palate  may  at  times  interfere  with 
a  child’s  nursing.  This,  like  the  difficulty  of  retracted 
nipple,  often  can  be  overcome  by  patient,  conscientious 
work  of  the  mother.  Many  cases  which  seem  hopeless 
at  first,  after  a  week  or  two  of  devoted  care  by  the  un- 


129 


tiring  mother,  may  learn  in  some  way  or  another  to 
obtain  milk  from  the  breast. 

The  difficulty  not  infrequently  met  with,  most  ex¬ 
asperating  both  to  the  mother  and  to  the  physician, 
ignorance  of  which  leads  to  the  greatest  dangers  to  the 
child,  is  with  the  so-called  neuropathic  child.  The 
mother’s  breast  may  be  abundantly  supplied  with  milk. 
The  slightest  pressure  applied  may  cause  the  milk  to 
gush  forth.  The  child,  however,  when  put  to  the  breast, 
takes  one  or  two  swallows,  then  seems  to  show  an  abso¬ 
lute  lack  of  interest  in  anything  connected  with  his 
feeding  and  lies  gazing  off  into  distance,  playing  with 
the  nipple 

Analysis  of  this  type  of  case  shows  not  infrequently 
that  two  factors  are  concerned :  The  one  is  simple 
weakness.  The  baby  has  been  born  with  little  strength, 
and  when  placed  to  the  breast  tires  rapidly  and  wants 
a  rest  between  drinks.  The  more  important  factor, 
however,  is  a  neuropathic  constitution.  In  the  latter 
case  the  infant  usually  is  a  child  of  nervous  parents; 
often  the  only  child  at  that.  He  has  come  into  the 
world  with  an  incompletely  developed  nervous  system. 
The  swallowing  reflexes  are  not  as  they  should  be,  the 
child  making  clumsy,  awkward  attempts.  The  breast 
milk  is  all  right  in  every  way ;  there  is  absolutely  noth¬ 
ing  wrong  with  it;  the  difficulty  is  solely  with  the  child, 
and  that  difficulty  not  a  serious  one.  This  objection, 
like  many  others,  can  by  perseverance  and  education 
frequently  be  overcome.  Usually  after  the  second  week 
the  child  has  learned  to  swallow  properly.  If  after  the 
third  week  he  still  shows  a  marked  aversion  to  the 
breast,  a  very  good  tentative  diagnosis  of  idiocy  may 
be  made.  Children  who  show  after  three  weeks  of  time 
a  marked  aversion  to  the  breast  are  almost  invariably 
backward,  feeble-minded  babies.  But  you  see,  gentle¬ 
men,  what  grave  errors  might  arise  from  not  under¬ 
standing  this  condition.  The  mother  in  great  trouble 
says  to  you,  “My  child  absolutely  will  not  nurse.  I 
have  tried  everything  possible,  and  he  will  not.  He 
doesn’t  like  my  milk,  and  I  think  we  ought  to  wean 
him  and  give  him  the  bottle.”  When  the  physician 
weakly  hearkens  to  this  plea  of  the  mother  the  new 
born  child  is  placed  upon  artificial  feeding  and  sub¬ 
jected  to  its  resulting  dangers  and  disasters.  In  these 

9 


130 


cases  humor  the  mother,  if  you  will ;  treat  her  any  way 
that  will  bring  you  results.  If  she  be  of  the  type  that 
wishes  the  quality  of  her  breast  milk  changed,  get  a 
specimen  of  breast  milk,  tell  her  that  the  fat  or  protein 
or  something  else  is  not  quite  up  to  normal,  give  her 
some  medicine,  and,  after  a  few  days  or  weeks,  tell  her 
that  her  milk  is  responding  nicely;  but  under  no  cir¬ 
cumstances  remove  the  child  from  the  breast. 

The  entrance  of  milk  into  the  breast  occurs  between 
the  first  and  eighth  day,  usually  about  the  fourth.  In 
many  cases,  however,  it  is  delayed,  and  you  are  asked 
by  all  concerned,  “Can  we  hasten  this  process?”  Gen¬ 
tlemen,  there  is  one  and  only  one  lactagogue  which  you 
may  use  with  any  degree  of  assurance,  and  that  lacta¬ 
gogue  is  the  nursing  infant.  The  one  stimulus  to  a 
breast  is  the  stimulus  arising  from  this  source.  In  the 
European  clinics,  where  many  wet  nurses  are  used, 
where  one  woman  sometimes  nurses  four  or  five  babies, 
these  wet  nurses  often  secrete  2  to  3  quarts  of  milk 
daily.  The  greater  the  stimulus  to  the  breast  the 
greater  the  response.  And  so,  gentlemen,  to  hasten  the 
entrance  of  milk  into  the  lagging  breast,  urge  the  fre¬ 
quent  application  of  the  infant.  Between  times  one 
may  use  the  breast  pump,  but  this  latter,  in  connection 
with  massage,  electricity,  and  the  use  of  all  other  arti¬ 
ficial  aids,  is  infinitely  less  efficient  than  the  normal, 
natural  method. 

If  in  spite  of  frequent  regularly  repeated  applica¬ 
tions  of  the  babe  to  the  breast  the  milk  still  delays, 
how  long  shall  we  wait?  Safely  a  few  days;  and 
during  this  time  must  we  he  very  careful  not  to  en¬ 
tirely  appease  his  appetite  with  artificial  food.  We 
want  to  keep  this  babe  hungry;  we  want  him  to  tug 
good  and  hard  at  the  breast  when  nursing;  and,  there¬ 
fore,  during  these  days  we  offer  him  only  a  little  water 
and  tea.  By  this  method  can  we  frequently  accelerate 
the  appearance  of  the  milk. 

However,  gentlemen,  don’t  focus  your  attention  so 
carefully  upon  the  mother  that  you  forget  the  child ; 
don’t  allow  your  zeal  for  hunger  lead  you  into  the  great 
error  of  letting  the  child  suffer  too  much  from  hunger. 
In  all  these  cases,  as  I  have  repeated  over  and  over 
again,  our  index  is  the  baby’s  weight  curve.  As  you 
know,  the  physiologic  loss  of  weight  during  the  first 


131 


few  days  amounts  to  from  one-half  to  one  pound,  and 
this  loss  should  he  recovered  within  the  second  week. 
If  by  this  time  the  baby  still  is  losing  or  shows  no 
tendency  whatsoever  toward  gain,  we  consider  this 
the  danger  signal,  and  direct  our  attention  more  to  the 
babe  and  less  to  the  mother.  We  must  put  the  child  to 
the  breast  more  frequently,  or,  in  case  this  is  impossi¬ 
ble,  add  a  little  bottle  to  the  diet.  We  must  never  for 
a  moment  let  the  baby’s  hunger  get  to  such  a  point  that 
he  develops  weakness,  because  if  he  becomes  too  weak 
to  nurse  properly  we  defeat  our  own  purpose.  This 
treatment  should  be  applied,  also,  to  those  weak  and 
those  neuropathic  children  who,  in  spite  of  a  rich  of¬ 
fering  of  milk,  do  not  drink  enough.  Let  the  weight 
curve  be  your  guide,  and  if  this  does  not  ascend,  in¬ 
crease  the  number  of  nursings  or  add  a  milk  mixture 
after  each  application  to  the  breast. 

What  shall  be  the  diet  of  the  nursing  mother?  As  far 
as  we  know  now,  the  nursing  mother  may  eat  absolutely 
anything  which  agrees  with  her  and  makes  her  happy 
and  contented.  We  may  disregard  totally  the  man¬ 
dates  of  our  grandmothers  in  this  respect.  If  the  nurs¬ 
ing  mother  likes  vinegar,  and  it  agrees  with  her,  let 
her  have  it.  Whatever  she  craves,  whatever  she  can 
digest,  whatever  pleases  her  and  makes  her  happy  and 
contented,  she  shall  have.  Our  sole  desire  in  regula¬ 
ting  her  diet  shall  be  to  fulfill  three  requirements : 

a.  She  must  have  enough  food.  Many  a  poor  woman 
does  not  secrete  a  good  supply  of  milk  because  she,  her¬ 
self,  is  starving. 

b.  The  food  must  be  digestible.  The  nature  of  the 
food  depends  upon  the  mother’s  social  condition  and 
her  taste;  but  anything  that  she  can  digest,  she  may 
eat. 

c.  Lastly,  we  must  gratify  her  thirst.  The  mother 
secretes  about  a  quart  of  breast  milk  a  day.  This 
means  almost  a  quart  of  water  in  addition  to  the  other 
normal  excretions.  You  see,  then,  gentlemen,  that  this 
woman  has  every  reason  to  be  thirsty.  Here  is  where 
many  mistakes,  even  by  well  educated  physicians,  are 
made.  The  physician  takes  advantage  of  this  thirst 
to  force  extra  food.  The  woman  does  not  need  extra 
food  at  this  time — her  normal  appetite  is  taking  care 
of  that — but  she  needs  fluid.  This  should  be  given  as 


132 


water,  tea,  broth,  and  thin  soup.  How  wrong  is  it, 
then,  to  take  advantage  of  this  need  of  fluid  to  throw 
into  her  body  a  great  excess  of  starches,  such  as  are 
contained  in  thick  .soups  and  gruels !  The  woman  does 
not  need  this  excess  of  food,  provided  she  is  getting  her 
meals  normally.  She  needs  simply  more  water. 

“Can  the  supply  of  breast  milk  be  influenced  as  re- 
gards  quantity  and  quality?”  It  is  the  idea  of  the 
laity,  particularly  of  the  grandmother  who  has  raised 
seven  children  and  the  aunt  who  has  raised  ten,  that 
the  quality  of  breast  milk  is  affected  by  many,  many 
influences,  by  psychic  and  nervous  changes  in  the 
mother,  by  pregnancy,  and  by  menstruation.  As  a 
matter  of  fact,  scientific  experiments  showing  changes 
in  quality  of  breast  milk  are  very  few  indeed. 

You  must  remember  that  the  amount  of  breast  milk 
secreted  at  each  nursing  varies.  You  must  remember 
that  the  amount  of  the  individual  ingredients  secreted 
during  the  individual  nursing  varies — fat  being  small 
in  amount  at  the  beginning  of  the  nursing  and  increas¬ 
ing  in  amount  toward  the  end  of  the  period.  To  get 
definite,  clean-cut  exneriments  not  subject  to  criticism, 
one  must  obtain  twenty-four-hour  specimens  of  breast 
milk,  analyze  them  very  carefully ;  and  repeat  this  upon 
successive  days.  The  number  of  such  experiments 
which  will  withstand  searching  criticism  is  few,  but 
those  experiments  which  have  been  made,  suggest  that 
nervous  and  psychic  factors,  pregnancy,  and  menstrua¬ 
tion  positively  have  no  effect  upon  quality  of  breast 
milk.  Undoubtedly,  children  show  disturbance  at 
times,  particularly  during  the  menstrual  period;  but 
our  present  observations  tend  to  show  that  these  dis¬ 
turbances  are  due  to  change  in  quantity  rather  than  in 
quality  of  the  breast  milk;  less  milk  is  secreted,  the 
child  is  hungry,  becomes  peevish,  irritable,  and  fretful, 
and  the  natural  conclusion  is  that  the  quality  of  the 
milk  is  changed ;  that  the  milk  is  not  agreeing  with  the 
child.  As  far  as  we  know  now,  however,  the  only  defi¬ 
nite  change  is  one  of  quantity,  and  this  usually  a  dimi¬ 
nution  of  total  secretion. 

As  regards  the  influence  of  diet  upon  the  breast  milk, 
we  despair  more  and  more.  Yo  one  in  experiments  de¬ 
void  of  criticism  has  definitely  shown  that  he  can  con¬ 
trol  at  will  the  quality  or  quantity  of  breast  milk  by 


133 


any  change  of  diet.  Many  of  the  statements  you  read 
as  to  the  efficiency  of  diet  are  based  upon  only  the  most 
superficial  of  investigations.  There  is  one  exception, 
perhaps,  and  this  is  with  fat.  In  underfed,  badly 
nourished  women,  high  fat  feeding  at  times  seems  to 
increase  the  fat  in  the  milk  secreted.  There  is  some 
doubt,  however,  as  to  whether  this  influence  is  exerted 
in  a  well-nourished  woman  or  not.  It  will  hold  only 
absolutely  true  for  the  undernourished  woman. 

As  regards  medicines,  every  drug  in  the  pharmacopeia 
has  been  tried  at  some  time  or  another  as  a  lactagogue. 
Each  one  has  in  turn  been  given  up.  The  latest  to 
be  tried  is  Pituitrin.  This,  in  definite  physiological 
experiment,  will  increase  the  amount  of  milk  in  a  given 
time;  but  again  are  we  doomed  to  disappointment.  The 
most  recent  observations  show  that  this  drug  acts  upon 
smooth  muscle  fibers;  that  it  causes  them  to  contract, 
thus  forcing  the  milk  more  rapidly  from  the  breast; 
but  that  in  absolutely  no  way  does  it  affect  the  total 
secretion. 

There  is  one,  and  only  one  agency  you  may  employ 
successfully  as  regards  improving  the  quality  of  breast 
milk,  and  that  is  recommendation  to  the  mother  of 
good  hygiene,  good  food,  fresh  air,  and  plenty  of  exer¬ 
cise.  Many  nursing  mothers  are  very  lax  in  this  matter. 
So,  to  summarize,  then,  we  may  say  that  as  regards 
influencing  the  quality  of  breast  milk,  we  are  practi¬ 
cally  helpless. 

Just  as  inefficient  as  are  our  methods  of  influencing 
quality  are  those  influencing  quantity.  Only  one  scheme 
is  known  definitely  to  increase  the  amount  of  milk 
secreted,  and  this  scheme,  gentlemen,  will  bring  woe  to 
you  if  you  attempt  it  in  private  practice.  In  an  insti¬ 
tution  where  wet  nu.rses  are  employed  one  may  stimu¬ 
late  a  lagging  breast  by  placing  to  it  a  healthy,  strong 
child.  This  proves  very  satisfactory;  but  woe  to  you 
if  you  suggest  to  your  private  patient,  with  her  nine 
generations  of  unadulterated  American  blood,  to  place 
to  her  aristocratic  breast  the  lustily  howling  infant  of 
the  common  folk — for  instance,  the  washwoman.  The 
wrath  of  mother,  grandmother,  grandfather,  uncles, 
aunts,  cousins,  and  neighbors  falls  heavily  upon  your 
head.  So,  gentlemen,  if  you  are  not  absolutely  sure  of 
your  practice,  in  such  cases  it  is  better  to  get  a  wet 


134 


nurse  from  the  start  or  to  add  a  supplementary  bottle 
after  each  feeding. 

As  a  general  rule,  I  have  found  the  following  scheme 
to  be  efficient  in  perhaps  999  out  of  1,000  cases:  Make 
up  your  mind  from  the  start  that  breast  milk  is  always 
all  right  in  quality.  Make  up  your  mind  that  the  only 
difficulties  that  arise  from  breast  feeding  are  those  due 
to  quantity.  Treat  the  mother  as  you  will  to  put  her 
mind  at  rest,  but  from  your  own  standpoint  conduct 
your  treatment  along  the  lines  of  correction  of  the 
amount;  and  if  you  keep  your  child  on  four-hour  feed¬ 
ing,  this  correction  will  usually  be  one  for  underfeeding 
rather  than  for  overfeeding. 

As  regards  the  general  technique  of  nursing,  during 
the  first  twenty-four  hours  some  men  do  not  place  the 
child  to  the  breast ;  others  do  once  every  six  hours.  As 
long  as  one  keeps  up  the  supply  of  fluids,  these  differ¬ 
ences  in  technique  are  of  little  importance.  Personally, 
I  believe  application  to  the  breast  is  better  for  its  stim¬ 
ulating  effect  upon  the  breast  and  possibly  upon  uterine 
contraction. 

As  regards  rigid  disinfection  of  the  breast,  we  are 
changing  ideas  more  and  more.  Where  *  the  mother 
practices  ordinary  cleanliness,  the  application  of  strong 
chemicals  to  the  nipples  is  absolutely  uncalled  for. 
Of  course,  in  the  very  poor  districts,  where  the  breasts 
are  caked  with  dirt,  they  must  be  washed  thoroughly; 
but  in  ordinary  private  practice  among  the  better  class 
families  the  use  of  a  little  piece  of  cotton  with  luke¬ 
warm  water  is  all  that  is  necessary.  If  the  mother  be 
one  of  the  modern  scientific  type,  and  wishes  something 
fashionable  and  antiseptic,  use  a  little  boric  solution. 
Personally,  however,  I  believe  that  the  use  of  a  strong 
antiseptic  is  a  frequent  cause  of  the  painful  fissured 
nipple. 

How  often  shall  we  put  the  baby  to  the  breast? 
Four-hour  feeding  was  reintroduced  by  Czerny  in  1905. 
Undoubtely,  the  majority  of  children  do  well  upon  this 
schedule  from  the  very  beginning — five  feedings  in 
twenty-four  hours.  Personally,  I  believe  a  small  per 
cent  have  difficulty  in  waiting  so  long,  and  so  as  to  in¬ 
clude  this  group  I  order  as  a  routine,  during  the  first 
four  to  six  weeks,  seven  feedings — one  every  three 
hours.  Undoubtedly,  the  majority  of  children  will  do 
just  as  well  upon  the  four-hour  schedule. 


135 


How  long  shall  we  allow  the  baby  to  nurse?  He 
shall  nurse  until  he  is  satisfied.  This  requires  usually 
from  fifteen  to  twenty  minutes.  The  first  five  of  these 
are  the  most  important,  for  in  the  first  five  the  baby 
gets  the  greatest  amount  of  milk.  You  easily  can  tell, 
gentlemen,  when  he  is  satisfied,  by  the  cessation  of  the 
swallowing  sound.  When  the  child  is  hungry  he  nurses 
vigorously  and  swallows  continuously.  When  he  ceases 
to  swallow  and  lies  playing  idly  with  the  nipple,  he  has 
had  enough.  If  the  child  empties  the  breast  thoroughly 
and  still  is  not  satisfied,  you  either  may  increase  the 
number  of  feedings  or  put  him  to  the  other  breast ;  but 
in  case  you  do  the  latter,  be  perfectly  sure  that  the  first 
breast  has  been  thoroughly  emptied.  A  child  is  easily 
spoiled,  and  if  the  second  breast  is  waiting  for  him, 
often  he  will  not  empty  thoroughly  the  first.  The  re¬ 
duction  of  this  stimulus,  then,  will  cause  a  correspond¬ 
ing  reduction  of  the  amount  of  milk  secreted. 

One  little  point  of  technique  frequently  is  overlooked, 
and  is  of  infinite  value  to  the  physician — one  our  grand¬ 
mothers  used  to  employ.  You  remember  our  old  grand¬ 
mothers  used  to  interrupt  the  nursing  at  intervals,  plac¬ 
ing  the  baby  upright  on  the  left  shoulder,  the  abdo¬ 
men  being  against  the  mother’s  body.  They  then  would 
pat  the  child  upon  the  back  until  he  belched  up  some 
air.  In  the  younger  days  of  science  any  practice  inter¬ 
fering  with  the  quiet  of  the  nursing  was  deprecated.  Re¬ 
cently,  however,  we  are  learning  that  there  is  much 
truth  in  our  old  grandmothers’  advice.  If  you  will  hold 
a  child  in  front  of  a  fluoroscope,  you  will  see  that  when 
nursing  he  frequently  swallows  air.  This  collects  in  a 
large  bubble  in  the  upper  part  of  the  stomach.  It  in¬ 
terferes  with  the  proper  filling  of  the  stomach.  It 
prevents  his  taking  sufficient  food,  often  makes  him 
vomit,  and  may  cause  colic.  If  you  break  the  nursing 
interval  every  few  minutes  and  pat  the  child  upon  the 
back  as  did  grandmother,  this  air  will  be  belched  up,  the 
tension  ip  the  stomach  relieved,  and  the  child  nurses 
with  renewed  vigor.  Many  almost  unsurpassable  diffi¬ 
culties  with  breast  feeding  are  overcome  by  this  simple 
little  bit  of  technique. 

In  instructing  the  mother  as  to  nursing,  tell  her  the 
baby  usually  does  better  if  he  has  not  only  the  nipple, 
but  also  a  little  of  the  areola  in  his  mouth. 


136 


How  shall  we  know  when  the  baby  is  doing  well? 
The  best  index,  gentlemen,  is  bis  weight  curve,  and  if 
be  gains  on  an  average  of  about  6  ounces  a  week,  no 
fault  should  be  found  with  his  nutrition. 

Just  a  word  about  the  feeding  of  prematures.  First, 
remember  that  in  every  case  of  premature  birth  you 
should  suspect  Lues;  not  that  this  disease  will  always 
be  met,  but  it  is  worth  considering.  Next,  remember, 
if  you  are  working  with  calories,  that  prematures  re¬ 
quire  more  calories  than  do  normal  babies.  Hr.  Julius 
Hess  of  our  city  made  a  nice  study  showing  this  higher 
caloric  requirement.  This  is  almost  self-evident,  of 
course,  for  the  premature  must  not  only  gain  as  does 
a  normal  baby,  but  has  to  make  up  back  losses. 

A  very  interesting  point  in  the  treatment  of  prema¬ 
tures  I  learned  from  an  address  of  Langstein.  Up  to 
the  time  of  his  studies  the  mortality  of  these  babies  in 
bis  institution  was  very  high.  He  found  that  this  was 
due  to  their  great  weakness.  In  many  cases  these  chil¬ 
dren  when  put  to  the  breast  were  too  weak  to  take  the 
required  nourishment.  They  tired  before  they  got  suf¬ 
ficient  food,  and  rapidly,  from  the  resulting  hunger, 
developed  the  condition  of  decomposition  and  death. 
Langstein  found  that  by  forcing  feedings  either  with  a 
medicine  dropper  or  a  stomach  tube,  by  getting  more 
food  into  these  babies,  mortality  was  very  greatly  re¬ 
duced.  So,  gentlemen,  if  your  premature  is  not  gain¬ 
ing,  don’t  waste  time.  Put  him  to  the  breast  more  fre¬ 
quently.  If  be  still  does  not  gain,  force  more  food  into 
him,  first  with  a  medicine  dropper,  and,  if  this  fails, 
then  with  a  stomach  tube. 

In  conclusion,  I  wish  to  call  your  attention  to  a  most 
fascinating  point  in  physiology.  Clinical  observation 
has  long  taught  us  that  most  prematures  and  also  many 
twins  develop  during  the  third  or  fourth  months  severe 
anemias  and  bad  rickets.  This  is  an  almost  invariable 
rule.  It  was  the  great  Czerny  who  offered  an  expla¬ 
nation.  Just  see  the  composition  of  breast  milk.  In 
1  quart  of  breast  milk  there  is  of  a  grain  of  iron 
and  a  little  over  %  grain  of  calcium.  There  is  abso¬ 
lutely  insufficient  iron,  barely  enough  calcium,  to  cover 
the  needs  of  a  child’s  body  for  these  minerals.  It  was 
Czerny  who  suggested  that  during  the  last  three  months 
of  intra-uterine  life  storage  warehouses  of  iron  are  de- 


137 


veloped  in  the  body.  The  main  one  of  these  seems  to  be 
in  the  liver,  and  during  the  first  months  of  life,  until 
the  baby  gets  a  mixed  diet,  he  does  not  live  upon  the 
iron  of  the  breast  milk,  but  does  live  upon  the  iron  kept 
in  the  depot  of  the  body.  In  a  like  manner  Czerny 
has  suggested  a  calcium  depot,  although  the  latter  is 
not  quite  so  well  established  as  the  former.  How,  you 
see,  gentlemen,  why  prematures  develop  anemia  and 
rickets.  They  have  come  into  the  world  before  these 
depots  have  been  developed,  and  the  supply  of  iron  and 
calcium  in  the  breast  milk  is  insufficient  for  their  needs. 

If  you  wish,  then,  to  prevent  all  these  unpleasant  re¬ 
sults  and  dangers  in  the  treatment  of  your  prematures, 
practice  a  little  prophylaxis.  At  the  third  month  you 
may  add  a  little  iron.  This  can  be  given  in  the  form 
of  Ferri  Carbonas  Saccharatus  three  times  daily  in 
quantities  equal  to  the  amount  that  can  be  placed 
upon  the  point  of  a  knife.  It  mixes  well  with  water  in 
a  teaspoon.  Calcium  may  be  given  in  any  agreeable 
mixture  in  doses  of  5  to  10  grains  three  times  daily. 
Cod  liver  oil  is  best  given  as  the  phosphorated  cod 
liver  oil,  as  follows: 

Prescription:  01.  Morrhuae  Oz.  VIII 
01.  Phosph.  Drachm  I 

The  dose  is  1  teaspoon  three  times  daily,  each  tea¬ 
spoon  containing  1  drop  of  01.  Phosph.  and  thus  1/100 
of  a  gr.  of  phosph. 

If  you  practice  these  methods  of  prophylaxis  you  will 
be  really  gratified  with  your  twins  and  prematures ;  you 
will  be  glad  to  see  that  severe  anemias  do  not  develop, 
and  you  will  note  that  the  dreaded  rickets  will  appear 
only  in  a  mild  form. 

Gentlemen,  from  these  studies  of  physiology  you  un¬ 
derstand  now  why  I  have  insisted  upon  a  mixed  diet 
for  every  child  of  six  months  of  age.  The  purpose  is 
to  provide  for  some  of  these  known  deficiencies  and 
also  for  those  whose  existence,  though  now  unknown, 
may  be  revealed  in  future  observation  and  experiment. 


LECTURE  X 


THE  DISTURBANCES  ARISING  IN  THE 

BREAST-FED 

Gentlemen,  in  speaking  of  the  disturbances  of  the 
breast-fed,  we  prefer  to  consider  them  also  as  “Disturb¬ 
ances  of  Nutrition.”  Just  as  in  the  artificially  fed 
child,  so  in  the  breast-fed  are  the  symptoms  arising 
many  more  than  those  from  local  gastro-intestinal  irri¬ 
tation.  In  addition  to  symptoms  from  stomach  and 
intestines,  the  skin,  the  weight  curve,  the  nervous  sys¬ 
tem,  the  decreased  immunity  to  infections  show  also 
that  involvement  is  general. 

Disturbances  of  nutrition  arising  in  breast-fed  babies 
are  due  to  two  causes : 

I.  Exogenous  causes,  i.  e.,  outside  factors. 

These  may  be : 

a.  Errors  in  the  technique  of  nursing,  which  we  con¬ 
sidered  last  week,  and,  of  course,  improper  food  given 
in  addition  to  the  nursing. 

b.  Parenteral  infections.  These  are  becoming  more 
and  more  important. 

c.  Improper  nursing,  improper  care,  overclothing, 
and  overheating. 

d.  Let  me  emphasize  again :  diagnose  only  rarely 
changes  in  quality ,  but  much  more  frequently  changes 
in  quantity  of  breast  milk. 

II.  Endogenous  causes,  i.  e.,  those  due  to  the  baby 
himself — i.  e.,  to  his  constitution.  We  are  learning  to 
recognize  more  and  more  the  importance  of  the  baby’s 
constitution  as  a  factor  in  causing  trouble.  Our  studies 
show  that  there  are  two  distinct  types  of  constitution : 

a.  The  Exudative  type,  in  which  the  child’s  cheeks 
are  covered  with  infiltrated  encrusted  weeping  eczema, 
and, 

b.  The  Neuropathic  type,  in  which  the  thin,  pale, 
often  rigid  baby  shows  distinctly  neurotic  tendencies. 

More  and  more  are  we  learning  the  great  and  ever 
growing  importance  of  these  endogenous  factors.  Until 
very  recent  years  all  disturbances  arising  in  breast-fed 


139 


children  were  considered  due  chiefly  to  poor  milk,  and  a 
diet  for  the  mother  or  wet  nurse  was  prescribed.  Now 
we  realize  that  this  idea  was  wrong;  that  the  fault  very 
frequently  was  that  of  the  baby. 

Before  discussing  disturbances  of  nutrition,  let  me 
call  your  attention  to  two  isolated  symptoms — symp¬ 
toms  which  are  not  important  from  the  standpoint  of 
the  baby,  but  are  of  vital  importance  from  the  stand¬ 
point  of  your  practice. 

I.  The  first  of  these  is  vomiting.  This  exists  in  two 
distinct  types : 

a.  The  Atonic  type,  in  which  the  food  simply  rolls 
out  of  the  side  of  the  mouth,  and 

b.  The  Spastic  type,  in  which  the  food  is  regurgi¬ 
tated  with  considerable  force. 

Notwithstanding  this  symptom,  if  the  baby  is  gain¬ 
ing,  if  he  is  well  and  happy  and  contented,  by  all  means 
leave  him  alone.  Keep  your  eyes  open  for  errors  in 
the  technique  of  nursing,  such  as  overfeeding,  irregu¬ 
larity  of  feeding,  neglect  of  the  little  technique  of  pat¬ 
ting  the  baby  on  the  back,  and  too  rapid  feeding;  but 
frequently  will  this  vomiting  persist  in  spite  of  perfect 
and  unimpeacable  routine.  In  the  latter  case,  the  dis¬ 
turbance  is  due  probably  to  the  baby’s  constitution,  the 
fault  lying  with  a  hyperesthetic  mucous  membrane  or 
to  faulty  reflexes.  No  matter  what  be  the  underlying 
cause,  if  the  baby  is  thriving,  if  he  is  happy,  and  con¬ 
tented,  and  satisfied,  take  the  mother  into  your  confi¬ 
dence;  tell  her  this  condition  exists  frequently  in  chil¬ 
dren,  that  it  is  to  be  considered  almost  normal,  and 
explain  to  her  that  from  the  third  to  the  sixth  month 
vomiting  spontaneously  will  cease.  Remember,  gen¬ 
tlemen,  that  this  type  of  which  I  am  speaking  occurs 
perfectly  independent  of  nutritional  disturbance.  Py¬ 
loric  Stenosis  and  Pyloro  Spasm  give  persistent  vomit¬ 
ing,  but,  in  addition,  grave  symptoms  of  disturbed  nu¬ 
trition. 

II.  Abnormal  bowel  movements. 

a.  In  reading  the  text-books  you  will  find  described 
that  the  stool  of  the  normal  breast-fed  child  is  soft, 
homogeneous,  pasty,  yellow,  and  smooth.  This  un¬ 
doubtedly  is  a  normal  stool — indeed,  one  almost  might 
say  it  is  ultra-normal.  But,  gentlemen,  if  you  examine 
a  great  number  of  breast-fed  babies,  you  will  find  that 


140 


the  stools  are  green,  slightly  watery,  somewhat  acid, 
and  contain  mucus  and  curds.  These  you  will  find 
more  frequently  or  at  any  rate  fully  as  frequently  as 
the  ones  described  by  the  text-book.  In  spite  of  this 
apparent  abnormality,  the  baby  thrives,  gains  consist¬ 
ently,  is  happy,  contented,  and  satisfied.  Under  such 
circumstances  why  these  stools  are  not  to  be  considered 
normal  I  do  not  know.  The  text-book  ideal  stool  is 
almost  more  than  normal. 

The  cause  of  these  increased  stools  is  not  certain. 
It  may  lie  in  intestinal  fermentation;  it  may  lie  in  a 
neuropathic  constitution;  it  probably  is  to  be  found  in 
both.  But  as  long  as  the  baby  is  happy  and  contented 
and  gaining,  leave  him  alone  and  instruct  the  mother 
that  in  this  type  of  child  this  stool  is  absolutely  normal. 

Tell  her  that  usually  it  will  correct  itself  by  the 
third  to  sixth  month.  If  it  does  not,  we  can  be  of 
service  in  a  way  to  be  mentioned  later. 

b.  Constipation.  In  discussing  the  constipation  that 
occurs  independent  of  nutritional  disturbance,  let  me 
present  an  idea  of  my  own.  I  present  this  to  you 
purely  as  an  idea,  not  as  a  fact — one  which  you  may 
in  your  leisure  moments  consider,  but  not  necessarily 
believe.  For  my  own  purposes,  I  divide  constipation 
into  two  types.  These  two  you  will  not  find  described 
in  text-books,  but  this  classification  has  been  of  great 
value  to  me. 

(1)  The  type  which  I  call  pseudo  constipation.  In 
this  the  baby  is  perfectly  happy,  contented,  and  thriv¬ 
ing.  His  bowel  movements  occur  perhaps  once  in  two 
days.  They  are  normal,  soft,  and  homogeneous.  The 
mother  complains  to  you  bitterly.  She  has  read  in  her 
guide  book  or  has  been  instructed  by  the  family  phy¬ 
sician  that  unless  the  bowels  move  once  a  day  the  baby 
will  not  sleep  well,  will  be  very  restless,  will  have  colic. 
As  a  matter  of  fact,  gentlemen,  these  symptoms  exist 
only  in  the  mother’s  mind.  They  are  in  the  guide 
book,  or  in  advice  obtained  from  outside  sources ;  but  in 
the  baby  they  do  not  exist.  He  goes  sailing  along  per¬ 
fectly  independent  of  the  anxiety  which  he  is  causing. 
Gentlemen,  has  it  ever  occurred  to  you  to  question  the 
authority  which  states  that  a  baby  must  have  one 
bowel  movement  a  day?  Frequently  have  I  asked  my¬ 
self,  “What  right  ha£  this  author  to  state  definitely 


141 


that  a  child  must  have  one  bowel  movement  daily?  We 
do  not  lay  down  definite  rules  as  to  the  frequency  of 
urination.”  We  know  that  this  depends  upon  many 
different  factors. 

The  text-books  make  the  definite  statement,  but 
where  is  their  authority?  It  comes  from  books  written 
in  previous  times.  These  books  when  written  were 
founded  upon  more  previous  observations,  and  ulti¬ 
mately,  I  presume,  we  would  find  the  statement  to  have 
originated  in  the  ages  gone  by,  in  those  medieval,  mys¬ 
terious  ages  when  knowledge  was  dogma,  when  wisdom 
was  superstition.  In  this  type  of  case,  usually,  I  tell 
the  mother,  “In  this  baby  this  condition  is  normal. 
Don’t  worry.  The  baby’s  intestine  is  so  strong  that  he 
is  absorbing  most  of  his  food ;  very  little  remains  in  the 
intestine,  and  two  days  are  required  for  sufficient  resi¬ 
due  to  accumulate  to  cause  a  normal  bowel  movement.” 
As  I  say,  gentlemen,  this  idea  may  be  wrong,  but  it 
gives  good  practical  results. 

(2)  The  type  which  I  call  true  constipation  requires 
more  definite  treatment.  In  this  child  the  stools  are 
definitely  hard  and  soapy,  i.  e.,  truly  constipated.  They 
do  not  adhere  to  the  diaper,  and  the  baby  may  strain 
and  have  pain.  Ho  matter  how  well  the  child  may  be 
thriving,  if  he  strains,  woe  be  to  you  if  you  tell  the 
mother  to  leave  him  alone.  If  you  wish  to  retain  your 
practice,  you  must  suggest  definite  therapy.  How  shall 
we  proceed?  First,  we  must  make  a  careful  examina¬ 
tion  to  rule  out  any  organic  cause,  such  as  tumor  or  a 
congenitally  dilated  colon.  Shall  we  give  physics? 
This,  of  course,  is  not  a  reasonable  procedure.  Physics 
simply  flush  out  the  bowel,  but  do  not  improve  the 
fundamental  cause.  Enemas  often  do  more  harm  than 
good.  When  these  are  repeated  daily  the  child’s  rectum 
becomes  sore  and  he  voluntarily  restrains  himself  so 
as  to  avoid  the  pain.  Thus  we  defeat  our  own  purpose. 
If  the  mother  demands  active  treatment,  an  enema  of 
1  ounce  or  more  of  olive  oil  may  be  introduced  into  the 
rectum-  once  or  twice  a  week.  Advise  this  just  before 
the  baby  goes  to  sleep,  instruct  the  mother  to  hold  the 
buttocks  together  so  that  the  oil  remains  in  the  intes¬ 
tine  all  night,  and  in  the  morning,  either  spontaneously 
or  from  a  mild  suppository  the  child  will  have  a  soft 
bowel  movement. 


142 


As  regards  correcting  the  underlying  cause,  we  must 
attempt  as  closely  as  possible  to  simulate  the  normal. 
In  the  perfectly  normal  breast-fed  child  a  state  of  mild 
fermentation  exists  in  the  intestine.  As  you  gentle¬ 
men  remember  from  the  lecture  on  artificial  feeding, 
such  a  condition  may  easily  be  produced  by  the  use  of 
carbohydrate.  Offer  your  patient  after  each  nursing 
an  ounce  or  more  of  cereal  water  with  5  per  cent  to 
10  per  cent  lactose,  or  else  add  from  V2  ounce  to  an 
ounce  after  each  nursing  of  a  10  per  cent  watery  solu¬ 
tion  of  malt  soup  extract.  In  addition,  use  fruit 
juices  and,  after  the  third  or  the  fourth  month,  a  little 
apple  sauce.  With  such  simple  procedure  these  cases 
respond  readily. 

TRUE  DISTURBANCES  OF  NUTRITION 

The  first  of  these  is  Inanition,  the  condition  arising 
from  insufficient  milk.  As  regards  symptoms  in  the 
gastro-intestinal  tract,  the  stools  usually  are  those  of 
the  truly  constipated  type,  being  infrequent,  dark,  and 
tenacious ;  but,  gentlemen,  let  me  urge  upon  you  strongly 
that  in  some  cases  stools  are  green,  watery,  and  contain 
mucus  and  curds.  Ho  worse  mistakes  can  be  made  in 
diagnosing  such  cases — as  is  so  frequently  done — as 
g astro-enteritis  from  overfeeding. 

The  general  symptoms  showing  that  the  state  of  nu¬ 
trition  also  is  affected  are  cessation  of  the  normal  gain 
in  weight,  pallid,  inelastic  skin,  lost  agility,  and  sunken 
abdomen.  The  nervous  system  is  involved.  Often  the 
child  cries  continuously,  showing  neurotic  tendencies 
by  scratching  the  skin  of  the  face  and  body  and  even  by 
rubbing  it  off  of  the  foot-soles.  Crying,  however,  may 
be  entirely  absent. 

In  the  etiology  of  the  condition  two  factors  are  to  be 
considered : 

1.  From  the  standpoint  of  the  mother  retracted  nip¬ 
ples,  fissured  nipples,  or  insufficient  milk  may  be  funda¬ 
mental. 

2.  From  the  other  standpoint,  however — and  what  so 
frequently  is  overlooked  or  underestimated  by  the  phy¬ 
sician — is  the  fundamental  importance  of  the  child.  In 
twins  or  prematures  weakness  may  be  solely  to  blame. 
A  neuropathic  constitution  is  frequently  the  basis  of 
the  whole  trouble,  and  creates  a  distracted  physician 


143 


and  a  most  perturbed  household.  In  the  new-born 
neuropathy  will  show  itself  by  undeveloped  swallowing 
reflexes.  These  we  considered  last  week.  During  the 
third  or  fourth  month,  however,  this  constitution  shows 
itself  in  more  persistent  form,  viz.,  'prolonged  loss  of 
appetite,  Ho  matter  how  much  milk  is  in  the  breast, 
do  what  you  will,  the  little  fellow  takes  no  interest  in 
his  food,  takes  one  or  two  swallows,  and  then  plays  idly 
with  the  nipple.  He  looks  around  the  room,  smiles,  is 
happy,  but  will  not  nurse.  These  are  the  cases  in  which 
the  distracted  mother  insists,  “My  milk  is  no  good ;  the 
baby  absolutely  refuses  it.”  These  are  the  cases  in 
which  the  unfortunate,  innocent  physician  gets  a  wet 
nurse.  Added  to  his  worries  now  are  not  only  com¬ 
plaints  of  the  mother,  but  also  the  domestic  infelicity 
which  arises  from  the  mother’s  superintending  the 
nursing  technique  of  the  new  acquisition  to  the  family. 
The  baby  refuses  the  breast  of  the  first  wet  nurse,  and 
a  new  one  is  employed.  Sometimes  four  or  five  are 
obtained  before  the  unhappy,  by  this  time  well-nigh 
insane,  physician  realizes  that  fundamentally  the  fault 
did  not  lie  with  the  breast  milk,  but  did  lie  with  the 
baby. 

DIAGNOSIS 

First,  is  this  a  case  of  inanition,  or,  if  the  stools  be. 
dyspeptic,  is  it  a  case  of  overfeeding?  Gentlemen,  in¬ 
stead  of  wasting  time  speculating,  simply  weigh  the 
baby  for  a  day  or  two  before  and  after  each  nursing. 
If  he  got  only  a  few  ounces,  no  matter  what  be  the 
nature  of  the  stool,  he  did  not  get  enough.  If  he  gets  8 
or  9  ounces  at  a  feeding  he  is  getting  too  much.  This 
simple  procedure  makes  a  difinite  diagnosis. 

More  important  is  it  to  diagnose  the  cause.  Re¬ 
tracted  or  fissured  nipples  speak  for  themselves.  If  the 
fault  be  insufficiency  of  milk,  the  baby  comes  to  the 
breast  and  after  five  or  ten  minutes  ceases  nursing  and 
cries  irritably.  Examination  of  the  breast  at  this  time 
shows  it  to  be  empty,  or,  if  the  nursing  be  interrupted, 
one  finds  that  the  milk  oozes  from  the  nipple  simply 
drop  by  drop. 

If  the  fault  lie  with  the  child,  observation  of  the 
nursing  process  makes!  the  diagnosis.  The  clumisy 
swallowing  of  the  new-born  points  to  undeveloped  re- 


144 


flexes;  the  lack  of  interest  in  the  older  child  shows 
the  neuropathic  loss  of  appetite. 

Prognosis. — In  the  breast-fed  baby  this  is  relatively 
good.  Rarely  does  the  breast-fed  child  ever  progress 
to  the  true  stage  of  decomposition  so  easily  reached  by 
the  bottle-fed  baby.  Decomposition  results  only  in 
extreme  cases. 

Treatment. — This  depends  upon  the  cause. 

1.  If  the  fault  lies  with  insufficient  milk,  the  child 
may  be  put  to  the  breast  more  frequently  or  else  both 
breasts  may  be  used.  If  the  weight  curve  does  not  show 
a  rise  after  a  few  days  of  this  treatment,  a  bottle  may 
be  added  after  each  nursing,  the  amount  depending 
upon  the  amount  of  milk  obtained  from  the  breast.  As 
children  wean  themselves  rapidly,  never  give  the  child 
the  bottle  until  the  breast  has  been  thoroughly  emptied. 

2.  When  the  fault  lies  with  the  child : 

( a )  If  it  be  due  to  the  undeveloped  reflexes  of  the 
new-born,  patience  must  be  exerted  by  the  mother,  and 
the  condition  corrects  itself  in  a  few  weeks.  But  dur¬ 
ing  this  time  see  that  the  baby’s  nutrition  does  not 
suffer,  and  see  that  the  breast  is  emptied  after  each 
nursing,  so  that  the  supply  does  not  fail. 

( b )  If  the  fault  lie  with  the  loss  of  appetite,  correc¬ 
tion  is  more  difficult.  Sometimes  a  few  drops  of  pepsin 
with  dilute  hydrochloric  acid,  given  a  few  minutes  be¬ 
fore  each  meal,  seem  to  stimulate  the  appetite.  A  daily 
stomach  washing  may  be  of  value.  A  lukewarm  bath  fol¬ 
lowed  by  a  cool  spray  occasionally  gives  striking  re¬ 
sults.  Gentlemen,  in  the  latter  be  very  careful  not  to 
shock  the  child.  Babies  are  very  susceptible  to  cold. 
Make  the  spray  just  cool  enough  to  be  mildly  stimula¬ 
ting  and  to  make  the  child  breathe  deeply — to  make 
him  cry,  perhaps,  but  under  no  circumstances  to  shock 
him  severely.  If  this  is  done  once  or  twice  a  day  a  few 
minutes  before  meal  times,  often  the  child  nurses  with 
considerably  more  vigor. 

During  this  period  of  treatment  the  child’s  nutrition 
must  by  no  means  be  neglected.  Here  great  errors  are 
made.  The  physician  too  frequently  says,  “If  this 
child  won’t  nurse,  we  will  let  him  get  so  hungry  that 
he  will  have  to.”  Such  treatment  accomplishes  noth¬ 
ing.  The  child’s  loss  of  appetite  is  not  due  to  his  hav¬ 
ing  obtained  sufficient  food.  It  is  due  to  the  condition 


145 


of  his  nervous  system.  Whether  you  give  food  more 
frequently  or  less  frequently,  his  appetite  will  not 
change  unless  the  underlying  fault  can  be  corrected. 
Under  these  circumstances,  as  the  baby  takes  only  the 
slightest  amount  of  food  at  each  nursing,  put  him  to 
the  breast  oftener ,  and  then,  if  his  weight  curve  doesn’t 
ascend,  use  forced  feeding,  even  the  stomach  tube,  be¬ 
cause  there  is  no  reason  for  his  nutrition  suffering  dur¬ 
ing  the  period  that  you  are  trying  to  overcome  his 
nervous  tendencies.  Lastly,  as  this  neuropathy  is  in¬ 
herited  from  nervous  parents,  as  the  baby  makes  the 
mother  nervous  and  the  mother  in  turn  makes  the  baby 
more  nervous,  at  times  the  only  thing  we  can  do  is  to 
order  a  change  of  environment.  If  you  can  get  a  good 
wet  nurse,  a  sane  woman  who  takes  a  perfectly  disin¬ 
terested  sort  of  interest  in  the  child,  results  frequently 
are  very  gratifying. 

3.  In  all  cases,  no  matter  what  be  the  cause  of  the 
inanition,  don’t  neglect  the  child’s  water  supply.  Chil¬ 
dren  suffer  grievously  from  lack  of  water.  In  getting 
small  quantities  of  breast  milk,  naturally  they  reduce 
markedly  their  water  intake.  In  your  treatment  don’t 
neglect  to  make  up  this  deficiency. 

The  other  marked  disturbance  of  nutrition  on  the 
breast  is  dyspepsia.  This  is  very  much  like  the  dyspep¬ 
sia  arising  on  the  bottle. 

The  gastro-intestinal  symptoms  are  those  of  vomit¬ 
ing,  regurgitation,  diarrhea,  anorexia ,  flatulence,  tym¬ 
panites,  and  colic. 

General  symptoms  other  than  those  of  the  intestinal 
tract  are  change  of  weight  curve,  change  in  the  quality 
of  the  skin,  slight  temperature,  nervous  reactions,  as 
sleeplessness  and  unrest,  and  decreased  immunity  to  in¬ 
fection. 

Etiology. — Several,  factors  may  be  concerned : 

1.  Alimentary  influences  up  to  the  present  have  been 
considered  most  important,  and  of  these : 

(a)  Overfeeding  is  given  by  all  text-books  the  first 
place.  Gentlemen,  I  don’t  want  to  be  too  radical,  but 
I  believe  that  more  and  more  are  we  beginning  to  doubt 
the  importance  of  overfeeding  as  a  cause.  As  the  im¬ 
portance  of  constitution  grows  in  our  mind,  as  we  begin 
to  recognize  the  exudative  and  the  neuropathic  type  of 

10 


146 


child,  as  we  learn  to  recognize  fundamental  differences 
in  the  baby  himself,  just  so  much  are  we  decreasing 
our  emphasis  on  the  outside  factors.  Irregularity  of 
feeding,  in  our  mind,  is  perhaps  of  much  more  import¬ 
ance  than  is  overfeeding,  and,  let  me  remind  you  that 
irregularity  of  feeding  is  due  frequently  to  underfeeding 
rather  than  to  overfeeding.  Indeed,  we  even  are  begin¬ 
ning  to  doubt  whether  many  cases  of  dyspepsia  on  the 
breast  result  from  overfeeding.  So  great  is  the  adapta¬ 
bility  of  the  mother’s  breast  to  the  baby’s  demands — 
when  a  baby  wants  more,  more  is  secreted;  when  the 
baby  wants  less,  less  is  secreted — so  great  is  this  adapta¬ 
bility  that  if  the  baby  be  nursed  regularly  every  four 
hours  it  is  a  question  whether  many  mothers  can  over¬ 
feed  their  babies.  Perhaps  overfeeding  is  a  factor  in 
those  cases  in  which  an  undernourished  baby  is  put  to 
the  breast  of  a  fine  healthy  wet  nurse.  Before  the  baby 
has  adapted  itself  to  the  breast,  and  vice  versa,  often 
too  much  milk  is  taken.  Such  statements  are  of  course 
heresy,  gentlemen ;  but  weigh  the  baby  before  and  after 
nursing  and  see  for  yourselves. 

( b )  Of  alimentary  factors,  we  believe  irregularity  of 
nursing  to  be  most  important;  and  never  forget  inani¬ 
tion  may  produce  a  picture  identical  to  dyspepsia. 

( c )  Foreign  substances  secreted  in  breast  milk  and 
causing  this  dyspepsia  we  believe  very  rare  indeed. 

( d )  Shifting  proportions  of  the  different  elements, 
as,  for  example,  too  much  fat,  are  frequently  described. 
Undoubtedly,  some  breast  milk  contains  more  fat  than 
the  average.  As  the  stools  of  many  of  these  children 
are  typically  fermentative,  frequently  do  I  wonder 
whether  perhaps  too  much  sugar  is  not  being  secreted. 
In  all  cases,  however,  very  little  clear-cut,  definite,  ex¬ 
act,  scientific  evidence  proves  that  disturbances  arise 
from  this  cause..  We  may  learn  more  of  this  later.  As 
I  mentioned  in  our  last  lecture,  one  will  make  fewest 
grave  errors  for  the  present  if  he  considers  that  invari¬ 
ably  breast  milk  is  absolutely  perfect  in  quality,  and 
disturbances  are  due  only  to  changes  in  quantity. 

2.  Infections. — The  more  dyspepsias  on  the  breast, 
the  more  do  we  realize  the  fundamental  influence  of 
infection.  A  baby  has  been  thriving,  becomes  infected 
with  a  naso-pharyngitis,  a  bronchitis,  an  otitis,  or  a 
cystitis,  and  a  dyspepsia  results.  When  the  infection 


147 


has  run  its  course  the  intestinal  tract  corrects  itself, 
fermentation  ceases,  and  the  stools  again  become  nor¬ 
mal.  It  is  this  type  of  case  in  which  such  frequent 
errors  are  made.  The  mother  says  the  milk  is  not 
agreeing  with  the  baby.  The  physician  may  prescribe 
a  wet  nurse ;  may  take  the  baby  from  the  breast ;  may 
order  medicine  for  the  child ;  may  diet  the  mother,  and, 
in  spite  of  all  treatment,  improvement  occurs.  Why? 
Gentlemen,  improvement  does  not  occur  from  the  ther¬ 
apy;  it  occurred  at  this  time  because  the  child  had 
recovered  from  the  infection.  In  all  cases  of  dyspepsia 
on  the  breast,  don’t  neglect  searching  for  parenteral 
infections. 

3.  Our  old  friends,  overclothing,  overheating,  im¬ 
proper  care,  overcooling,  are  of  course  never  to  be  for¬ 
gotten. 

The  symptoms  depend  to  some  extent  upon  the  cause. 
Those  due  to  alimentary  factors  develop  gradually. 
Nervous  changes  evidence  themselves  first  with  dis¬ 
turbed  sleep  and  restlessness.  Later  symptoms  of  the 
gastro-intestinal  tract  develop.  General  symptoms  and 
fever  are,  as  a  rule,  not  very  severe.  The  type  due  to 
infection  appears  rather  suddenly  in  the  previously 
thriving  child.  General  symptoms  and  fever  are  more 
in  evidence  than  in  the  previous  types. 

The  severity  of  the  reaction  and  the  course  depend 
upon  the  child’s  constitution  ;  the  better  the  constitu¬ 
tion  the  less  the  reaction.  The  alimentary  type  is  usu¬ 
ally  somewhat  progressive  and  often  ends  in  anorexia. 
The  infectious  type  is  short  and  ends  in  a  cure  with 
recovery  from  infection. 

The  pathogenesis  is  not  absolutely  known,  hut  proba¬ 
bly  has  to  do  with  carbohydrate  fermentation  in  the 
intestinal  tract. 

The  diagnosis  is  made  from  the  history. 

The  treatment  is '  relatively  easy  where  alimentary 
factors  can  be  corrected.  Where  infection  is  the  basis 
of  the  disturbance,  wait.  In  both  types,  and  also  in  the 
type  which  was  mentioned  at  the  beginning  of  the  lec¬ 
ture,  powdered  casein  is  of  great  value.  Formerly, 
this  could  be  obtained  as  powder.  Since  the  war,  I 
doubt  if  it  is  obtainable ;  but  we  may  make  it  ourselves 
by  getting  the  curds  of  mi^k  and  putting  them  through 
a  sieve.  You  remember  that  casein  is  the  great  agent 


148 


for  making  the  intestine  alkaline,  and  as  most  of  these 
diarrheas  are  of  a  fermentative  acid  nature,  casein  is 
the  ideal  substance  to  meet  our  requirements.  Give  it 
in  doses  of  one  or  two  teaspoons  after  each  nursing  and 
increase  until  you  obtain  the  desired  results. 

One  must  never  neglect  the  general  care  of  the  child 
and  inquire  earnestly  into  the  conditions  in  the  house¬ 
hold,  his  clothing  and  general  hygiene. 

One  danger  in  the  treatment  leads  frequently  to 
serious  complications.  The  mother  or  the  physician, 
not  recognizing  that  an  infection  is  the  cause,  lays 
great  emphasis  upon  the  importance  of  the  breast  milk. 
Something  must  have  changed  the  quality  of  the  breast 
milk.  Therefore,  we  shall  take  the  baby  from  the 
breast  and  not  put  him  back  until  the  milk  has  cor¬ 
rected  itself,  and  put  nothing  into  the  stomach  until 
the  stools  are  normal.  In  this  treatment,  gentlemen, 
all  that  we  have  accomplished  is  to  add  to  our  patient’s 
troubles  the  damaging  influence  of  hunger.  Frequently 
he  gets  better  with  this  treatment;  but  this  change  is 
due  to  cessation  of  the  infection.  Under  these  circum¬ 
stances,  gentlemen,  don’t  make  unnecessary  use  of  hun¬ 
ger  in  your  treatment.  Children  have  so  much  intelli¬ 
gence — often  so  much  more  than  we — if  you  weigh  this 
baby  before  and  after  nursing  you  will  find  that  in¬ 
stinctively  he  cuts  down  his  diet.  You  will  find  that 
he  drinks  far  less  during  these  few  days  than  he  does 
ordinarily.  It  is  my  custom  simply  to  put  the  children 
to  the  breast,  allow  them  a  shorter  interval  than  that 
to  which  they  are  accustomed — five  minutes,  for  ex¬ 
ample — and  to  repeat  this  at  the  regular  feeding  time, 
but  never  to  let  them  hunger  markedly.  By  ,this  pro¬ 
cedure  will  you  find  that  the  baby’s  general  nutrition  is 
maintained  during  these  few  trying  days. 

From  the  above  considerations,  gentlemen,  you  see 
how  unnecessary,  in  many  cases,  is  a  wet  nurse.  The 
fault  lies  so  frequently  with  the  baby  rather  than  with 
the  milk,  so  frequently  with  outside  factors,  such  as 
infections,  rather  than  with  the  mother  serself. 

Just  one  word  about  very  severe  diarrheas  occurring 
in  the  breast-fed.  Breast-fed  children  rarely,  it  is  true, 
but  still  definitely  develop  symptoms  almost  identical 
to  the  alimentary  intoxication  of  the  bottle  baby.  Our 
previous  ideas  were  that  a  toxin  was  being  secreted  by 


149 


the  breast  milk.  I  believe  this  has  been  definitely  dis- 
proven.  I  doubt  if  people  ever  find  human  breast  milk 
definitely  poisonous  to  the  child.  However,  in  these 
cases  we  are  learning  to  recognize  other  factors.  We 
are  learning  that  parenteral  infections  may  be  at  fault ; 
that  true  intestinal  infections,  such  as  dysentery,  that 
overheating,  may  all  be  the  basis  of  the  trouble;  and, 
lastly,  we  are  learning  to  recognize  that  children  in 
states  of  severe  decomposition  or  intoxication,  when 
fed  large  quantities  of  any  breast  milk  whatsoever,  go 
down  and  die  with  the  severest  alimentary  symptoms. 

The  treatment  in  these  conditions  is  identical  to  that 
of  the  alimentary  intoxication  of  the  artificially  fed. 

This  finishes,  gentlemen,  the  subject  of  infant  feed¬ 
ing.  There  are  many,  many  phases  of  this  interesting 
subject  which  I  should  like  to  discuss  with  you.  Time, 
however,  forbids.  If  you  have  followed  me  carefully, 
you  will  perhaps  have  obtained  some  idea  of  the  meth¬ 
ods  of  our  Middle  West  as  I  understand  them.  I  do 
not  urge  these  exclusively  upon  you.  I  trust  that  you 
have  become  interested  and  will  investigate  the  teach¬ 
ings  of  the  great  men  all  over  this  country  of  ours. 
After  you  have  a  comprehensive  view  of  the  whole  field, 
select  the  method  which  pleases  you  most,  or,  better  yet, 
with  your  perfectly  neutral  viewpoint,  you  may  be  in  a 
position  to  select  from  the  different  teachings  many 
points  of  value,  and  I  trust  that  you  will  be  able  to  use 
them  all,  no  matter  what  be  their  source,  to  aid  sick 
and  suffering  children. 


LECTURE  XI 


ACUTE  ANTERIOR  POLIOMYELITIS 

Gentlemen,  you  have  requested  a  discussion  of  acute 
Anterior  Poliomyelitis.  This  disease  is  of  particular 
interest,  not  only  due  to  the  present  epidemic,  but  also 
because  its  history  is  of  comparatively  recent  origin 
and  because  this  history  shows  our  ever  steady,  suc¬ 
cessful  progress.  From  great  groups  of  paralyzed 
crippled  children  Heine,  a  German  physician,  in 
the  year  1840  thought  he  recognized  a  distinct  disease, 
described  it  as  children’s  paralysis,  and  reasoned  that  it 
must  have  its  origin  in  the  spinal  cord.  In  1860  he  re¬ 
described  this  condition  with  more  emphasis,  insisted 
upon  it  as  a  clinical  entity,  and  again  insisted  that  it 
must  be  related  to  the  spinal  cord.  Cornil,  a  French¬ 
man,  in  1863  by  pathological  studies  showed  that  in 
these  cases,  changes  were  to  be  found  in  the  anterior 
horn  cells  of  the  gray  matter  of  the  spinal  cord.  Re¬ 
peatedly  has  this  observation  been  confirmed.  Of  ex¬ 
treme  value  were  contributions  of  the  French  school  in 
the  year  1883.  Having  obtained  for  the  first  time  per¬ 
fectly  fresh  specimens,  they  showed  that  the  inflamma¬ 
tion  was  not  limited  to  the  anterior  cells  exclusively, 
but  extended  throughout  the  entire  gray  matter,  and 
even  at  times  involved  some  of  the  white.  Thus  by  the 
year  1883  our  knowledge  had  so  far  progressed  that  we 
knew  the  condition  to  be  not  exclusively  an  anterior 
poliomyelitis,  but  a  diffuse  inflammation  of  the  cord, 
a  true  myelitis.  Strange  that  this  observation  has  at¬ 
tracted  so  little  notice.  Repeated  confirmation,  how¬ 
ever,  from  all  parts  of  the  world  proves  its  truth. 

At  present  our  knowledge  of  the  pathology  may  be 
summed  up  as  follows : 

A.  Of  the  cord. 

1.  Gross  examination  of  a  freshly  cut  section  shows 
the  cord  to  be  swollen,  edematous,  dark  red  with  slight 
protrusion  of  the  gray  matter.  These  areas  of  involve¬ 
ment  exist  as  cylinders  scattered  throughout  the  cen¬ 
tral  nervous  system  about  half  an  inch  in  length  and 
follow  the  course  of  the  blood  vessels. 


151 


2.  Microscopic  examination. 

( a )  The  fresh  specimen  would  show  a  profuse  in¬ 
flammation  throughout  the  whole  gray  matter,  being 
most  marked,  however,  around  the  anterior  cells.  The 
inflammation  is  most  marked  along  the  course  of  the 
vessels,  which  are  dilated,  distended,  and  often  throm¬ 
bosed.  The  ganglion  cells  show  all  stages  of  degenera¬ 
tion.  A  slight  meningitis  is  noticeable. 

( b )  Examination  of  an  old  case  shows  no  evidence 
of  acute  inflammation.  The  gray  matter  has  practi¬ 
cally  recovered,  with  the  exception  of  destruction  of  the 
anterior  horn  cells ;  and  in  their  place  is  scar-tissue 
formation.  These  changes  are  most  marked  in  the 
lumbar  segments. 

B.  As  regards  the  other  organs. 

1.  A  fresh  case  shows  inflammation  and  irritation  of 
the  mucous  membrane  of  the  intestine. 

2.  In  an  old  case  the  affected  muscles  have  atrophied 
almost  to  disappearance  or  have  been  replaced  by  fat 
infiltration.  The  bones  of  the  affected  extremity  are 
.shortened  and  decreased  in  thickness. 

Just  as  our  progress  in  diseases  of  nutrition  required 
first  the  exhaustion  of  pathology  and  required  the  newer 
aids,  such  as  repeated  clinical  studies  and  studies  of  an 
etiological  nature,  just  so  have  we  required  these  aids 
in  our  study  of  acute  anterior  poliomyelitis. 

Clinical  Studies. — Among  the  first  of  the  clinicians 
to  lay  emphasis  upon  the  infectious  nature  of  the  dis¬ 
ease  was  Strumpell  of  Leipzig.  He  argued  that  from 
the  mode  of  onset,  the  sudden  rise  of  fever,  the  gastro¬ 
intestinal  symptoms,  the  perspiration,  and  the  general 
malaise,  the  disease  must  be  an  infection ;  but  he  gave 
no  proof.  Epoch-making  in  this  respect  was  the 'Study 
of  Medin  in  1899  and  of  Ivan  Wickman  in  1905,  both 
of  Sweden,  who  carefully  studied  and  described  epi¬ 
demics  of  this  disease.  From  these  extremely  import¬ 
ant  studies  we  learn  that  the  disease  is  not  only  infec¬ 
tious,  but  also  is  contagious  in  nature;  that  not  only  is 
it  transmitted  from  patient  to  patient,  but  also  that  it 
may  be. carried  by  a  second  person.  Studies  of  epi¬ 
demics  from  all  over  the  world  repeatedly  have  con¬ 
firmed  these  first  brilliant  observations.  A  large  epi¬ 
demic  was  described  in  Hew  York  in  1907  and  1908. 
Few  of  the  observers  lay  such  definite  emphasis  upon 


152 


the  contagiousness  of  the  disease  as  did  Wickman,  with 
the  exception  of  Mueller  in  Marburg  and  Treves  in 
England.  The  latter  epidemic,  consisting  of  only  eight 
cases,  is  of  special  interest,  because  Treves  is  able  to 
show  that  there  was  a  clear-cut  definite  incubation 
period  of  six  days  as  the  disease  traveled  from  patient 
to  patient. 

From  the  standpoint  of  clinical  observation  these 
studies  are  of  incalculable  value.  They  have  shown: 

1.  The  incubation  varies  from  one  to  eight  days. 

2.  The  disease,  though  infinitely  more  common  in 
children,  not  rarely  attacks  adults. 

3.  The  disease  is  essentially  a  summer  sickness,  rag¬ 
ing  particularly  during  the  months  of  July  to  October. 

4.  As  regards  means  of  distribution,  the  infection 
seems  to  follow  the  railroads,  country  roads,  and  per¬ 
sonal  contact  among  neighbors.  Transmission  seems 
to  be  essentially  of  human  source. 

5.  Of  particular  value  were  these  studies  in  eluci¬ 
dating  atypical  types.  Before  the  days  of  Wickman, 
severe  nervous  diseases,  such  as  encephalitis,  acute 
ataxia,  and  Landry’s  paralysis,  had  been  ascribed  to 
undiscovered,  unknown,  mysterious  cases.  Sudden  in¬ 
crease  of  these  clinical  entities  during  periods  of  polio¬ 
myelitis  epidemic  show  that  these,  too,  must  be  classed 
as  belonging  to  that  disease. 

6.  Lastly,  Wickman  ha.s  brought  to  our  attention  the 
abortive  types  of  this  infection.  A  little  child  is  taken 
sick,  shows  the  slightest  transient  paralysis,  and  recov¬ 
ers  speedily.  Only  the  occurrence  of  an  attack  of  acute 
anterior  poliomyelitis  in  his  brother  or  sister  just  pre¬ 
vious  to  or  just  following  this  attack  shows  that  this 
child  has  suffered  from  an  abortive  attack  of  this 
disease. 

THE  SYMPTOMS 

Prodromes  are  rare.  Occasionally  does  the  mother 
tell  you  that  the  child  has  suffered  from  loss  of  appe¬ 
tite.  As  a  rule,  however,  the  child  is  stricken  sud¬ 
denly. 

The  onset  may  show  five  different  variations: 

1.  The  abortive  type,  in  which  the  paralysis  is  very 
slight  and  transient.  Usually  this  is  overlooked,  unless 
it  occurs  during  an  epidemic. 


153 


2.  The  meningeal  type,  in  which  the  onset  is  typical 
to  that  of  acute  menigitis,  conclusions,  rigid  neck, 
Kernig,  and  coma  necessitate  an  immediate  lumbar 
puncture. 

3.  The  encephalic  type.  Convulsions  are  usually 
one-sided  or  involve  one  extremity;  but  the  coma,  the 
severe  vomiting,  the  strabismus,  and  the  changed  respi¬ 
ration  all  point  to  serious  intracranial  injury. 

4.  The  type  in  which  the  lesion  is  in  the  medulla  or 
in  the  pons  leads  to  rapid  death  from  circulatory  or 
respiratory  failure.  This  frequently  is  not  diagnosed 
without  the  presence  of  an  epidemic. 

5.  The  spinal  type  is  the  one  which  you  gentlemen 
will  be  most  likely  to  meet,  and  therefore  just  a  few 
words  about  the  symptoms. 

I.  The  initial  stage  is  characterized  by  a  sudden  on¬ 
set,  with  fever  reaching  sometimes  105  degrees.  A  chill 
is  rare.  In  this  stage  a  sore  throat,  coryza,  or  bronchi¬ 
tis  may  be  evident.  Perspiration  is  profuse.  The  baby 
vomits,  and  may  show  intestinal  disturbance  severe 
enough  to  be  associated  with  bloody  stools.  The  main 
symptoms  are  those  of  the  nervous  system.  Drowsi¬ 
ness  and  apathy  may  give  way  to  coma.  Convulsions, 
especially  in  the  encephalic  type,  may  monopolize  your 
attention.  Pain  of  a  meningeal  nature  is  almost  invari¬ 
ably  present,  and  leads  frequently  to  a  false  diagnosis. 
Pain  is  most  marked  in  the  back  and  in  the  legs.  As 
the  child  not  infrequently  has  just  met  with  an  injury, 
the  mother  may  complain  to  you  of  the  knee  joint. 
Careful  examination,  however,  will  show  that  the  pain 
is  not  limited  exclusively  to  the  knee,  but  that  the  child 
cries  whenever  the  extremity  is  touched.  The  child 
does  not  wish  to  be  disturbed  or  moved.  Suboccipital 
headache  may  be  most  severe.  Rarely  are  there  sphinc¬ 
ter  disturbances,  no-r  are  there  disturbances  of  sen¬ 
sation. 

As  you  see,  gentlemen,  during  this  stage  the  symp¬ 
toms  are  those  of  acute  infection.  Nothing  definite 
can  as  yet  be  said.  We  exhaust  our  means  of  diagnosis. 
We  make  a  blood  count.  Up  to  recently  leucopenia  was 
considered  characteristic.  In  this  recent  epidemic,  how¬ 
ever,  we  see  that  blood  counts  have  varied  up  to  12,000. 
So  from  leucocyte  counts  we  obtain  little  of  value. 


154 


A  lumbar  puncture  in  many  cases  absolutely  is  indi¬ 
cated.  In  beginning  cases  the  fluid  escapes  under  slight 
increase  of  tension.  It  is  clear,  however;  shows  no 
marked  change  in  the  cell  count,  but  does  show  evi¬ 
dences  of  spinal  cord  irritation,  such  as  positive  globu¬ 
lin  test. 

The  technique  for  these  is  as  follows.  The  Hoguchi 
test  is  the  most  valuable. 

(a)  Noguchi: 

.2  cc.  centrifuged  fluid  in  test  tube. 

Add  .5  cc.  10%  butyric  acid.  Boil  and  quickly  add 

.1  cc.  4%  NaOH  and  boil  again. 

(A  fine  or  coarse  granular  precipitate  is  positive — 
usually  found  within  20  minutes.  If  not  found  at  the 
end  of  2  hours,  absolutely  negative.) 

(b)  Ross- Jones: 

1  part  sat.  sol.  aqueous  Ammon.  Sulph.  superimpose 
equal  vol.  of  C.  S.  fluid  by  allowing  to  flow  down  side 
of  slanted  test  tube. 

A  contact  ring  white  and  granular  in  3  minutes  is 
positive. 

\ 

II.  This  stage  of  maximum  intensity  lasts  up  to 
£even  days,  the  fever  falling  usually  on  the  third  or 
fourth.  The  diagnosis  is  made  by  the  rapid  onset  of 
an  acute  severe  paralysis,  occurring  during  the 
first  twTenty-four  to  forty-eight  hours.  This  paralysis 
may  involve  any  group  of  muscles  or  all,  and  is  charac¬ 
terized  by  the  fact  that  it  comes  .suddenly  from  a  clear 
sky,  that  it  is  a  total  paralysis,  and  that  it  is  nonpro¬ 
gressive.  It  comes  with  one  severe  stroke,  and  does  not 
travel  from  muscle  group  to  muscle  group.  The  reflexes 
of  the  affected  muscles  are  diminished  if  the  lesion  be  in 
the  cord,  or  increased  if  it  be  in  the  brain.  During 
this  stage  not  infrequently  does  death  occur  from  the 
acute  toxemia  of  the  infection  or  from  paralysis  of  the 
respiratory  muscles.  This  stage  lasts  not  over  a  week, 
and,  if  the  child  be  spared,  rapidly  proceeds  to 

III.  The  period  of  retrogression.  For  the  first  six 
weeks  after  the  onset  of  the  paralysis  recovery  of  the 
infected  muscles  is  rapid.  After  these  six  weeks  recov¬ 
ery  proceeds  more  slowly,  but  it  is  said  does  continue  - 
for  months  or  even  years.  The  recovery  is  practically 
never  complete,  however.  Those  muscles  whose  ener¬ 
vating  cells  in  the  spinal  cord  have  been  absolutely 
destroyed  will  never  regain  their  function.  Which  mus¬ 
cle  groups  are  to  be  thus  affected  one  may  surmise  by 


155 


the  end  of  the  first  week.  At  this  time  atrophy  is 
already  marked  and  the  reaction  of  degeneration  pres¬ 
ent.  Gentlemen,  in  those  cases  where  the  reaction  of 
degeneration  is  early  present  the  prognosis  for  recovery 
is  bad.  These  muscles  atrophy  almost  to  disappear¬ 
ance,  the  bones  in  the  affected  extremities  become 
shorter  and  smaller,  the  surrounding  skin  cold,  cyam 
otic,  and  shows  vaso-motor  changes.  Contractures  de¬ 
velop  from 

(a)  Paralysis,  leaving  a  muscle  group  without  its 
antagonist ; 

(b)  Static  causes,  such  as  gravity  and  the  weight  of 
bed  clothing; 

(c)  Definite  contractures  in  the  affected  muscles 
from  changes  in  their  nutrition. 

Diagnosis. — The  diagnosis  is  relatively  easy.  His¬ 
tory  of  the  onset  followed  by  acute  paralysis  rules  out 
almost  every  other  condition.  A  few  rare  nervous 
lesions  may  cause  confusion.  These  might  be  hemor¬ 
rhage  into  the  cord,  Spina  Bifida  with  its  resulting 
paralyses,  birth  paralysis  and  congenital  muscular  de¬ 
fects.  The  pain  of  scurvy,  involving  as  it  does  particu¬ 
larly  the  knee  joint,  may  at  times  cause  confusion  with 
a  pain  associated  with  Poliomyelitis.  Perhaps  the  most 
confusing  condition  for  differentiation  is  a  multiple 
neuritis.  Careful  history  and  examination,  however, 
will  prevent  difficulties. 

The  history  of  multiple  neuritis  shows  a  previous 
typhoid,  scarlet,  diphtheria,  pertussis,  or  mumps;  or, 
in  an  older  child,  may  show  lead,  arsenic,  or  alcohol. 
Poliomyelitis  on  the  other  hand,  comes  from  a  clear 
sky,  with  one  stroke,  having  no  predisposing  cause. 

The  fever  in  multiple  neuritis  is  intermittent  and 
continuous,  often  lasting  for  weeks.  In  poliomyelitis 
the  fever  lasts  a  few  days. 

The  paralysis  in  multiple  neuritis  is  symmetrical  and 
often  progressive,  one  muscle  group  after  the  other 
being  involved,  and  the  course  is  prolonged.  In  poli¬ 
omyelitis  paralysis  is  usually  asymmetrical,  is  typi¬ 
cally  nonprogressive,  and  recovery  in  all  but  a  few 
muscle  groups  very  rapid.  If  the  upper  extremity  is 
affected,  multiple  neuritis  by  preference  selects  the 
muscles  enervated  by  the  radial  nerve,  poliomyelitis  the 
muscles  of  the  shoulder  girdle. 


156 


Prognosis. — Since  we  have  come  to  recognize  tlie 
severe  forms,  such  as  Landry’s  paralysis,  we  are  learn¬ 
ing  that  the  prognosis  as  to  life  is  not  as  good  as  was 
previously  held.  Still  in  the  majority  of  cases  children 
make  recovery. 

Treatment. — The  treatment  self-evidently  must  be  of 
the  cause.  Sane,  rational  treatment  must  be  directed 
to  overcoming  the  virulent  poison  and  neutralizing  the 
effects  of  the  agent  which  is  so  disastrous  to  the  cells 
of  the  central  nervous  system.  This  brings  us  to  the 
fascinating  studies  concerning  the  etiology  of  this 
disease. 

The  year  1909  was  epoch-making  as  regards  history. 
Studies  from  various  countries,  Flexner  and  Lewis  in 
New  York,  Leiner  and  Wiesner,  also  Landsteiner  and 
Popper  in  Vienna,  and  Roemer  and  Mueller  in  Mar¬ 
burg,  showed  that  by  injecting  the  medullary  substance 
of  patients  dying  with  this  disease  into  monkeys  the 
disease  could  be  transmitted  to  these  animals.  And, 
what  was  still  more  vital,  the  contagion  could  be  car¬ 
ried  from  one  infected  monkey  to  another.  So  the  year 
1909  shows  us  that  the  virus  causing  acute  anterior 
poliomyelitis  is  a  living  virus.  Prom  this  time  the 
studies  have  been  carried  on  mainly  by  the  brilliant 
group  of  scientists  of  the  Rockefeller  Institute  in  New 
York. 

Me  now  have  learned  that  the  disease  is  caused  by  a 
definite  micro-organism.  It  is  very  small,  barely  visible 
under  the  microscope,  but  can  be  obtained  from  the 
diseased  tissues,  and  grows  with  difficulty  in  artificial 
medium.  It  is  located  in  the  central  nervous  system, 
the  mucous  membrane  of  the  nose,  throat,  and  intestine, 
but  not  as  yet  found  in  the  blood  of  patients  sick  with 
this  disease.  No  matter  what  be  the  clinical  type  of  on¬ 
set,  the  location  is  the  same.  It  enters  the  body  through 
the  nose  and  throat,  whence  it  proceeds  by  lymphatics 
to  the  brain  and  cord.  No  matter  how  introduced  into 
the  body,  whether  by  the  nose,  throat,  or  intestine,  or 
whether  injected  into  the  abdomen,  blood,  or  brain,  in 
all  cases  does  the  virus  leave  the  body  by  means  of  the 
secretions  of  the  nose  and  throat  and  from  the  intestine. 
Healthy  persons  in  contact  with  a  sick  child  may  har¬ 
bor  this  virus  in  their  nasal  secretions  for  weeks.  One 
case  is  reported  definitely  in  which  a  healthy  person 
was  a  carrier  for  a  period  of  five  months. 


157 


The  virus  leaves  the  central  nervous  system  rather 
rapidly,  not  being  found  therein  for  longer  than  two 
weeks.  In  the  secretion  of  the  nose  and  throat  it  re¬ 
mains  longer,  generally  disappearing,  however,  after 
the  fourth  or  fifth  week. 

It  is  a  resistant  virus,  withstanding  drying  and  weak 
carbolic  solutions  very  well,  and  so  is  readily  adapted 
to  being  carried  by  fingers,  by  infectious  droplets, 
coughing,  sneezing,  kissing,  and  dust.  Attempts  have 
been  made  to  lay  the  blame  for  transmission  of  this 
virus  to  insects,  such  as  the  stable  fly,  mosquito,  bed¬ 
bugs,  and  lice.  This  has  not  as  yet  been  proven;  but 
one  thing  have  we  definitely  learned :  The  common 
house-fly,  after  being  allowed  to  feed  upon  nasal  secre¬ 
tions  of  a  sick  child,  may  harbor  the  virus  in  his  intes¬ 
tinal  tract  for  forty-eight  hours. 

During  periods  of  epidemic  domestic  animals  such 
as  pigs,  dogs,  cats,  and  poultry,  frequently  are  affected 
with  acute  paralyses.  Attempts  have  been  made  to  fix 
the  blame  upon  these  creatures,  but  newer  studies  have 
shown  that  these  paralyses  are  due  to  an  entirely  differ¬ 
ent  disease  and  should  in  no  way  be  confused  with 
poliomyelitis. 

The  disease  leaves  a  definite  immunity,  the  blood 
destroying  or  neutralizing  the  virus  for  over  twenty 
years  after  infection.  It  is  this  immunity  which  offers 
us  the  greatest  hope  for  a  successful  treatment.  Already 
have  vaccines  been  employed.  In  the  experimental 
work  their  use  has  been  attended  with  the  greatest  of 
success.  Animals  thus  injected  become  immune  to 
lethal  doses  of  the  virus,  but  the  occurrence  of  an  occa¬ 
sional  paralysis  during  this  treatment  makes  it  as  yet 
inapplicable  to  clinical  use.  Without  a  doubt  the  bril¬ 
liant  scientists  now  at  work  will  shortly  discover  the 
cause  of  this  danger,  and  by  weeding  it  out  will  offer 
us  the  one  great  hope  of  prevention  that  we  have. 

Hot  only  has  the  vaccine  treatment  proven  successful 
in  prophylaxis,  but  also  has  the  serum  of  recovered 
children  and  monkeys  proven  of  value  in  active  treat¬ 
ment. 

TREATMENT 

Prophylactic  treatment  requires  considerable  care.  If 
possible,  the  patient  should  be  placed  in  a  hospital 
ward.  Studies  have  shown  that  the  virus  is  easily  con- 


158 


trollable.  In  environments  of  good  hygiene,  where  the 
urine  and  howel  movements  are  disinfected,  where  the 
nasal  and  throat  secretions  are  caught  in  gauze  and 
burned,  where  promiscuous  handling  of  the  patient  is 
not  allowed,  never  does  the  disease  spread  by  direct 
contact.  It  is  as  readily  controllable  as  typhoid  in  a 
hospital  ward.  If  the  hospital  is  not  available,  the 
patient  should  be  isolated  in  his  home.  The  nurse  in 
charge  of  the  case  must  understand  thoroughly  that 
she  is  handling  an  acute  infectious  disease.  She  must 
understand  the  necessity  of  rigid  disinfection  of  all  the 
excreta ;  she  must  know  the  necessity  of  catching  the 
throat  and  nasal  secretions  and  burning  the  cloths;  she 
must  know  the  absolute  urgency  of  keeping  adults,  par¬ 
ticularly  anxious  parents,  from  fondling  the  sick  baby. 
All  our  observations  up  to  the  present  show  that  the 
disease  is  carried  more  by  human  source  than  by  any 
other  agency.  We  must  attempt  with  every  means  in 
our  power  to  protect  other  well  babies  from  the  danger 
of  adult  carriers  of  this  disease. 

Self-evident,  of  course,  is  proper  screening  and  pro¬ 
tection  of  the  infected  child  from  flies. 

ACTIVE  TREATMENT 

In  all  cases  where  serum  of  recovered  patients  may 
be  obtained  the  intraspinous  use  of  this  is  our  ideal 
procedure.  It  is  the  only  method  of  treatment  from 
which  we  may  hope  for  cure.  Lumbar  puncture,  how¬ 
ever,  must  be  made  with  care,  for  with  the  hyperemic 
condition  of  the  cord  sudden  relief  of  pressure  may 
result  in  hemorrhage.  Release  the  fluid  slowly  and 
gradually  and  inject  approximately  as  much  serum  as 
you  have  withdrawn  fluid.  This  must  be  repeated  sev¬ 
eral  times. 

Failing  serum,  one  may  in  desperation  try  the  recom¬ 
mendation  of  Meltzer,  viz.,  the  intraspinous  injection 
at  repeated  intervals  of  .5  to  1  cubic  c.  of  adrenalin 
chloride  in  salt  solution.  In  some  cases,  for  reasons 
which  I  do  not  know,  clinical  improvement  seems  to 
have  followed  this  treatment. 

Lastly,  urotropin  may  with  some  degree  of  ration¬ 
ality  be  given.  This  drug  is  an  antiseptic  and  is  known 
definitely  to  be  excreted  into  the  spinal  canal.  Monkeys 


159 


fed  with  urotropin  in  a  certain  proportion  of  cases  show 
more  resistance  to  infection  than  did  untreated 
monkeys. 

The  general  treatment  is  purely  symptomatic.  Pain 
may  be  relieved  by  narcotics  or  salicylates.  Severe 
convulsions  at  the  onset  not  infrequently  are  relieved 
by  the  diagnostic  lumbar  puncture.  Still  continuing, 
however,  they  may  be  controlled  by  bromides,  chloral, 
and  narcotics. 

Consensus  of  opinion  seems  to  be  that  a  prolonged 
period  in  bed  is  most  to  be  advised.  During  this  period 
massage,  electricity,  and  gymnastics  are  advised  and 
employed.  I  know  little  of  osteopathy,  but  it  seems  to 
me  that  this  condition  should  be  an  ideal  indication 
for  an  osteopath.  The  resulting  deformities  with  loss 
of  functions  are  best  to  be  treated  along  surgical  lines, 
and  by  muscle  transplantation. 

Recent  and  almost  experimental  in  nature  is  the  sur¬ 
gical  procedure  of  nerve  transplantation.  The  surgeons 
take  a  nerve  from  an  unimportant  group  of  muscles  and 
transfer  it  to  the  degenerating  affected  nerve  of  a  more 
important  group.  In  this  way  restoration  of  function 
sometimes  results,  and  this  surgical  procedure  offers  us 
considerable  hope. 


LECTURE  XII 


OBSCURE  CAUSES  OF  FEVER 

Gentlemen,  today  I  thought  we  might  consider  some 
of  the  obscure  causes  of  fever,  cases  which  you  are 
called  to  see,  where  fever  is  present,  hut  where  physical 
diagnosis  is  absolutely  negative.  It  is  in  this  group  of 
cases  that  the  children’s  specialist  has  considerable  ad¬ 
vantage  over  the  general  practitioner.  To  go  into 
detail  would  require  too  much  time,  and  so  I  am  just 
going  to  give  you  a  little  scheme  by  way  of  illustration. 

First.  You  are  called  to  see  an  infant  two  days  old. 
The  temperature  is  between  102  and  104  degrees. 
Physical  examination  is  absolutely  negative.  In  a  few 
days  the  temperature  may  go  down  or,  in  rare  instances, 
after  a  short  while  the  child  may  die.  A  diagnosis  has 
never  been  made. 

This  condition  has  most  forcibly  been  brought  to  our 
attention  by  Holt,  who  describes  it  as  Inanition  Fever. 
It  is  due  to  failure  of  the  breast  to  secrete  milk,  the 
child  meanwhile  suffering  from  insufficient  food  and 
from  what  now  is  believed  to  be  even  more  important, 
insufficient  water.  With  the  appearance  of  milk  in  the 
breast  and  the  satisfying  of  the  child’s  demands  for 
fluid  the  condition  disappears.  In  rare  cases  where 
one  has  concentrated  exclusively  upon  the  child,  failing 
to  note  the  insufficiency  of  breast  milk,  death  may  occur 
from  lack  of  food.  In  such  cases  if  the  breast  does  not 
start  secreting  after  a  reasonable  period,  get  a  wet 
nurse  or  order  a  bottle,  and  your  troubles  will  be  over. 

Second.  You  are  called  to  see  a  premature  or  the 
smaller  one  of  twins.  The  child  has  a  temperature  of 
105,  hut  physical  examination  reveals  nothing.  Half 
an  hour  after  your  examination  the  temperature  is 
normal.  Don’t  forget,  gentlemen,  that  these  little  chil¬ 
dren  are  very  susceptible  to  external  temperature.  In 
this  latter  case  the  child  has  been  in  an  overheated  in¬ 
cubator  or  has  been  surrounded  by  too  many  hot-water 
bottles  and  too  heavy  blankets,  taking  on  the  tempera¬ 
ture  of  the  surrounding  atmosphere.  During  your  ex¬ 
amination  the  little  one  becomes  cooled  again.  ♦  Never 


161 


forget,  when  you  examine  a  weak  child  with  fever — 
before  you  get  ready  your  doses  of  medicine,  the  enema 
can,  and  your  hypodermics — to  examine  the  environs 
in  which  the  little  one  has  been  placed. 

A  mother  brings  a  little  child  of  four  to  six  years  of 
age  fearful  of  tuberculosis.  There  is  a  history  of  tuber¬ 
culosis  in  the  family.  The  child  coughs  and  expecto¬ 
rates.  The  temperature  is  down  in  the  morning  and 
up  every  evening.  Examination  is  without  result.  The 
Pirquet  Test  is  negative.  Sputum  examination  reveals 
no  tubercle  bacilli.  You  apply  more  delicate  tests,  in¬ 
jecting  tuberculin  into  the  skin — the  intracutaneous 
method.  This  is  of  no  avail.  In  desperation,  never¬ 
theless,  you  insist,  “This  must  be  tuberculosis  any¬ 
way/’  It  is  not,  however.  It  is  a  chronic  inflamma¬ 
tion  of  the  naso-pharynx.  Careful  examination  of 
throat  will  show  mucus  falling  from  the  back  of  the 
nose  into  the  pharynx.  Sometimes  infected  adenoids 
may  be  the  cause,  but  not  infrequently  this  condition 
exists  without  them.  Chronic  posterior  naso-pharyn- 
gitis  has  given  rise  to  many  false  diagnoses  of  tuber¬ 
culosis. 

The  next  condition  in  connection  with  the  subject 
of  infant  feeding  belongs  almost  exclusively  to  the  do¬ 
main  of  the  pediatrician,  so  common  is  it  to  be  found  in 
children.  After  an  attack  of  pharyngitis  you  are  called 
to  see  a  child  whose  temperature  may  be  104  or  105 
degrees.  You  search  carefully  for  the  cause  of  this 
fever  and  find  absolutely  nothing  other  than  perhaps 
a  very  slight  rigidity  of  the  head  or  neck,  tending  to 
a  mild  torticollis.  You  make  little  of  the  condition, 
order  medication,  and  leave.  A  few  days  later,  amid 
great  excitement  and  urgent  appeals,  you  hasten  to  the 
child’s  bedside.  He  is  cynanotic,  gasping  for  breath, 
and  he  holds  his  head  drawn  backward,  attempting  in 
every  way  possible  to-  relieve  pressure  upon  the  larynx. 
Respiration  is  accompanied  by  a  loud  gurgling  noise. 
You  ask  yourself,  “Can  I  possibly  have  overlooked  a 
laryngeal  diphtheria?”  You  get  your  incubation  outfit 
ready.  You  call  the  surgeon,  who  sharpens  his  knives, 
preparatory  to  performing:  tracheotomy.  Suddenly  the 
symptoms  are  relieved  by  the  rupture  of  a  retro-pharyn¬ 
geal  abscess.  Gentlemen,  no  condition  more  frequently 
is  overlooked  than  is  retro-pharyngeal  abscess  in  chil¬ 
dren.  Upon  inspection  of  the  throat  it  is  not  visible. 

11 


162 


It  can  never  be  seen  unless  it  bas  assumed  large  pro¬ 
portions.  Tbe  only  way  to  diagnose  it  when  suspected 
is  to  palpate  very  gently  the  back  of  the  throat  with 
the  finger.  The  abscess  is  apparent  as  an  area  of  soft 
fluctuation  about  the  level  of  the  base  of  the  tongue 
and  just  to  one  side  of  the  median  line  of  the  pharynx. 

The  treatment  consists  of  incision  with  a  guarded 
scalpel,  or,  better  yet,  guiding  yourself  with  a  finger  of 
the  left  hand  to  the  area  of  greatest  fluctuation,  with 
the  right  hand  insert  an  artery  forceps  about  a  quarter 
of  an  inch  and  spread  open.  Hold  the  child’s  head  for¬ 
ward  so  that  the  pus  gushing  forth  will  not  fall  into  the 
trachea  and  cause  pneumonia. 

It  is  not  necessary,  of  course,  to  remind  you  that 
syphilis  and  tuberculosis  cause  chronic  temperatures 
with  at  many  times  few  physical  findings.  In  all  cases 
of  persistent  temperature  never  forget  to  consider  these 
two  diseases. 

Again,  gentlemen,  the  telephone  rings  in  the  dead 
of  night.  The  mother  calls  you,  complaining  in  dis¬ 
tressed  tones :  “Reginald  has  a  terrible  attack  of  the 
colic.  The  poor  dear  is  suffering  terribly.  He  has 
vomited  up  some  sour-smelling  undigested  fluid,  and  I 
am  absolutely  sure  that  he  has  eaten  something  that 
is  producing  awful  indigestion.”  The  vibrating  win¬ 
dow-panes  responding  to  Reginald’s  lusty  cries  show 
you  that  the  mother’s  anxiety  may  to  some  extent  be 
justified.  You  rush  to  the  bedside,  give  peppermint 
water,  give  enemas  and  colonic  flushings,  order  hot 
water  bags  to  the  abdomen,  and  busy  grandmother  in 
making  a  turpentine  stupe.  As  a  matter  of  fact,  the 
child  is  suffering  from  otitis  media.  I  am  not  sure  as 
regards  this  climate,  but  at  home  whenever  a  child  gets 
any  sort  of  infection  of  the  respiratory  passages  he  gets 
almost  invariably  an  otitis  media.  Hot  necessarily 
does  this  infection  proceed  to  the  point  of  suppuration, 
but  it  does  proceed  to  a  point  sufficient  to  cause  pain. 
I  do  not  wish  to  tread  upon  the  ground  of  the  ear 
specialist,  but  from  the  standpoint  of  the  pediatrician 
otitis  media  with  very  simple  technique  can  frequently 
be  diagnosed.  In  a  normal  child,  if  you  exert  mild 
pressure  upon  the  tragus  he  pays  little  attention. 
I  don’t  mean,  of  course,  that  you  must  exert  sufficient 
pressure  to  attempt  to  penetrate  into  his  cranial  cavity. 
Be  very  gentle  and  mild.  If  the  child  is  crying,  he 


163 


continues  to  cry.  In  a  child  with  an  otitis  media  this 
same  mild  pressure  causes  him  definitely  to  wince,  to 
jerk  his  head  away  sharply,  to  screw  up  his  face,  and, 
if  he  is  not  crying,  to  cry  loudly.  I  dare  say  in  90  per 
cent  of  cases  with  this  simple  procedure  you  may  diag¬ 
nose  some  involvement  of  the  ear,  either  external  or 
middle.  So,  when  Reginald  has  the  colic,  especially 
if  he  has  a  little  cold  and  cough  at  the  same  time,  don’t 
forget  this  colic  may  be  otitis  media. 

Lastly,  you  are  called  to  see  a  rather  sick-looking 
infant,  usually  a  little  girl.  The  skin  is  pallid.  Dark 
rings  encircle  the  eyes.  The  appearance  is  so  character¬ 
istic  that  frequently  one  is  justified  in  suspecting  the 
diagnosis  from  first  glance  at  the  baby.  The  temper¬ 
ature  is  low  in  the  morning,  perhaps  subnormal,  and 
may  rise  to  104  or  105  in  the  afternoon.  Repeated 
physical  examination  is  of  absolutely  no  service.  The 
mother  tells  you  that  at  times  the  child  suffers  from 
colic.  You  diagnose  all  sorts  of  terrible  conditions. 
You  think  of  malignant  endocarditis  or  of  pyemia.  The 
temperature  curve  suggests  malaria  and  leads  to  large 
doses  of  quinine.  As  a  matter  of  fact,  gentlemen,  the 
child  is  suffering  with  a  pyelo-cystitis.  In  all  cases 
where  the  temperature  is  persistent  for  a  day  or  two, 
particularly  in  a  girl,  where  physical  examination  is 
negative,  insist  upon  a  urinalysis.  Many,  many  times 
will  you  be  rewarded.  The  centrifuged  specimen  will 
be  loaded  with  pus  cells.  In  order  to  make  these  cells 
more  apparent  a  drop  of  dilute  acetic  acid  added  to  the 
centrifuged  specimen  will  bring  out  the  nuclei  of  these 
cells  and  make  the  diagnosis  easier. 

In  treating  the  condition,  remember  that  it  runs  a 
rather  chronic  course.  The  urine,  contrary  to  adult 
cystitis,  is  acid.  ,  For  this  reason  hexamethylamine, 
which  acts  only  in  acid  medium,  may  be  given  in  doses 
of  1  grain  three  times  daily.  Remember,  however,  that 
this  drug  is  irritating  to  the  kidneys  and  should  be  used 
with  care.  Perhaps  the  best  treatment,  after  all,  is  the 
use  of  the  alkaline  diuretics,  potassium  citrate  or  ace¬ 
tate  in  doses  of  15  or  20  grains  daily,  and  increased 
until  the  urine  becomes  alkaline.  After  the  latter  is 
accomplished  hexamethylamine  is  ineffective;  but  the 
simple  change  to  alkalinity  frequently  is  the  only 
therapy  necessary,  and  the  case  with  mild  remissions 
proceeds  rather  rapidly  to  cure. 


LECTURE  XIII 


CONVULSIONS 

Gentlemen,  when  called  to  a  case  of  convulsions  in  a 
child,  particularly  if  it  be  your  first  case,  you  will  be 
bewildered.  The  white-faced  mother,  the  anxious 
father,  the  severe,  critical  grandmother,  the  excited 
neighbors,  and  the  austere  nurse  all  look  at  you  more 
as  an  enemy  than  a  friend.  Mother  urges  you  to  do 
something  quickly.  Grandmother  says  to  the  neigh¬ 
bors,  “He  looks  so  young !”  The  nurse  looks  at  you 
with  the  expression  of  “Wonder  if  this  treatment  is 
going  to  be  like  that  of  Dr.  X”  who,  you  know,  looks 
wise  behind  his  ambush  of  whiskers.  Under  these 
trying  circumstances,  if  you  wish  to  be  completely 
master  of  the  situation  you  must  at  once  provide  work 
for  everybody.  Get  grandma  and  all  the  neighbors  out 
of  the  way  by  ordering  them  to  prepare  a  hot  bath. 
One  word  of  caution,  however.  Grandma  in  her  enthu¬ 
siasm  to  help  frequently  heats  the  water  hot  enough 
to  boil  the  baby.  Many  a  child  has  been  badly  injured 
in  this  way.  So  before  making  use  of  the  bath,  always 
test  the  temperature  first  with  your  finger.  Mother 
we  can  occupy  by  ordering  material  for  a  soap-suds 
enema.  Father  we  send  to  the  drug  store  for  .some 
medicine,  and  the  nurse  shall  undress  the  baby. 

In  treating  a  case  of  convulsions  don’t  make  the  mis¬ 
take  which  so  frequently  is  made,  namely,  considering 
that  you  have  done  your  duty  simply  by  relieving  the 
child  for  the  moment.  Don’t  forget  that  a  convulsion 
is  not  a  disease,  but  is  a  symptom,  a  symptom  of  some 
great  disturbance  of  the  nervous  system.  It  is  your 
duty  not  only  to  relieve  the  convulsion,  but  also  to 
study  the  child  carefully  and  to  attempt  to  determine 
the  cause.  The  treatment  of  the  immediate  convulsion 
is  easy.  Depending  upon  which  is  prepared  first,  the 
hath  or  the  soap-suds,  use  either  the  tub  or  the  enema. 
If  this  does  not  control  the  situation,  without  wasting 
any  more  time  you  may  resort  to  the  use  of  morphine. 
Give  a  hypodermic  of  gr.  1-100  to  a  new-born  baby,  of 
1-50  gr.  to  a  babe  of  six  months,  1-25  gr.  to  a  child  of 


165 


one  year,  and  1-16  gr.  to  a  two-year-old.  In  the  ma¬ 
jority  of  cases  morphine  is  sufficient.  If  not,  chloral 
hydrate  is  a  valuable  adjunct.  Send  for  Gr.  XV  and 
dissolve  these  in  a  little  starch  water.  Use  half  this 
solution  for  a  rectal  instillation,  thus  giving  about  Gr. 
YII  of  chloral.  The  child  quiets  in  ten  to  fifteen  min¬ 
utes  and  falls  into  a  peaceful  sleep  lasting  about  two 
hours.  If  the  first  injection  of  chloral  is  expelled,  the 
second  dose  may  be  given.  As  this  drug  is  very  irri¬ 
tating  to  the  stomach,  it  should  not  be  given  through 
the  mouth.  In  extreme  cases  a  few  whiffs  of  chloro¬ 
form  may  be  offered. 

Having  quieted  the  spasm,  your  duty  has  barely  com¬ 
menced.  It  is  not  sufficient  to  leave  and  to  tell  the 
mother,  “The  baby  is  over  its  trouble.  If  he  seems 
sick  again,  call  me.”  This  is  inexcusable  carelessness. 
In  such  a  case,  gentlemen,  it  is  our  duty  to  discover  the 
underlying  cause  of  the  disturbance.  For  this  reason 
I  have  prepared  a  little  table  showing  the  different 
causes  of  convulsions,  a  table  which  may  be  of  service 
to  you. 

I.  Convulsions  due  to  direct  irritation  of  the  brain. 

a.  Brain  hemorrhage  is  a  frequent  source  of  trouble. 
When  following  a  difficult  labor  or  following  instru¬ 
mental  delivery  the  baby  shows  spasms,  be  suspicious 
of  meningeal  hemorrhage. 

b.  Malformations  of  the  brain  in  children  of  alco¬ 
holic  or  degenerate  parents  frequently  causes  this 
symptom. 

c.  Hydrocephalus. 

d.  Brain  Tumor. 

e.  Brain  Abscess. 

Convulsions  due  to  the  above  are  characteristically 
without  fever  and  often  one-sided. 

II.  The  group  due  to  reflex  causes  is  emphasized 
particularly  by  American  authors.  Such  factors  would 
be 

a.  Severe  injury  or  accident. 

b.  Renal  colic. 

c.  Phimosis. 

d.  Uentition. 

e.  Worms. 

The  latter  three  we  shall  refer  to  later. 

III.  Another  group  particularly  emphasized  by  all 
writers  is  the  toxic  group. 


166 


a.  Don’t  forget,  gentlemen,  that  the  onset  of  any  in¬ 
fectious  disease  may  be  ushered  by  a  convulsion.  In¬ 
deed,  so  frequent  is  this  phenomenon  that  it  may  be 
compared  to  the  chill  of  an  adult.  When  called  to  such 
a  child,  when  the  convulsion  subsides  under  the  influ¬ 
ence  of  a  hot  bath  or  a  colonic  flushing,  don’t  say 
simply,  “Baby  ate  something  that  did  not  agree  with 
him.”  Tell  the  mother  that  the  above  might  have  been 
the  case,  but,  also,  “Mother,  possibly  the  baby  is  get¬ 
ting  scarlet  fever,  measles,  whooping-cough,  or  pneu¬ 
monia,”  and  in  your  own  mind  keep  reserved  menin¬ 
gitis,  and  in  times  like  the  present,  poliomyelitis. 
Convulsions  at  the  onset  of  an  infectious  disease  are 
of  little  signifiance,  but  a  convulsion  occurring  during 
the  course  of  an  infectious  disease  is  grave.  Such  an 
occurrence  means  that  an  area  of  inflammation  has 
been  established  in  the  brain  and  that  if  death  does  not 
occur  permanent  paralysis  will  result.  Beware  of  these 
convulsions  occurring  during  the  course  of  infectious 
disease. 

b.  Acute  nephritis  may  have  its  onset  with  a  con¬ 
vulsion.  Don’t  forget  urinalysis. 

c.  Food  is  an  important  factor,  either  good  food 
given  to  the  young  infant  in  improper  proportions  or 
spoiled  food  to  an  older  child. 

The  above  three  types  are  characterized  by  high 
fever.  When  called  to  such  a  case,  instead  of  ordering 
a  hot  bath,  one  may  sponge  the  baby  with  lukewarm 
water,  apply  cool  cloths  to  the  head,  give  a  bath  at  a 
temperature  slightly  below  that  of  the  body,  or  a  col¬ 
onic  flushing  of  water  a  few  degrees  below  that  of  the 
body. 

d.  One  of  the  toxic  causes  upon  which  not  sufficient 
emphasis  is  placed,  either  by  Americans  or  by  Euro¬ 
peans,  is  the  group  included  under  the  term  “Atelec¬ 
tasis.”  This  means  collapse  of  the  lungs.  You  would 
suspect  atelectasis  with  a  following  history:  The  baby 
is  a  premature,  is  the  smaller  one  of  twins,  or  is  simply 
a  weak  child.  He  usually  is  under  one  month  of  age. 
The  mother  or  nurse  tells  you,  “This  is  the  best  baby  I 
ever  have  seen.”  He  sleeps  all  the  time ;  he  never  cries ; 
he  doesn’t  fuss  about  his  bottle.”  When  you  get  this 
history,  beware !  The  baby  is  not  quiet  because  he  is 
unusually  good;  he  is  quiet  because  of  his  extreme 


167 


weakness.  He  is  too  weak  to  cry.  He  is  too  weak  to 
call  for  his  food.  Mother  or  nurse,  thinking  he  is  so 
good,  doesn’t  wake  him  up  for  his  feedings.  Hot  get¬ 
ting  sufficient  food,  his  strength  becomes  less  and  less. 
The  muscles  of  respiration  are  affected,  and  one  fine 
day  they  are  not  strong  enough  to  move  his  chest.  He 
is  too  weak  to  breathe,  and  now  the  little  alveoli  of  the 
lungs  collapse.  He  becomes  very  cyanotic,  and  when 
the  carbon  dioxide  tension  in  the  blood  becomes  suffi¬ 
ciently  high  a  convulsion  results. 

Vou  see,  gentlemen,  what  a  terrible  mistake  one 
would  make  by  treating  this  child  as  one  treats  the 
others.  What  this  child  needs  is  not  depressants,  is 
not  chloroform,  not  chloral,  not  bromides,  certainly  not 
morphine ;  but  what  he  needs  is  stimulation.  He  needs 
a  hypodermic  of  camphor  in  oil,  a  hypodermic  of 
adrenalin,  oxygen,  if  obtainable,  and  artificial  respira¬ 
tion.  He  may  be  placed  in  a  warm  mustard  bath  and 
sprayed  very  gently  with  water  just  a  bit  cooler  than 
that  of  the  bath.  But  remember  that  he  is  almost  dead, 
and  under  no  circumstances  do  anything  to  cause  any 
sort  of  a  shock.  Having  combatted  the  acute  attack, 
shall  we  leave,  thinking  we  have  done  our  duty?  Under 
no  circumstances.  This  child  may  have  fifteen  such 
attacks  a  day.  We  must  instruct  nurse  or  mother  con¬ 
stantly  to  be  on  the  lookout  for  a  recurrence.  We 
rapidly  must  build  up  this  baby’s  strength.  We  must 
wake  him  up  regularly  for  feeding,  and  if  he  be  too 
weak  to  nurse,  we  must  force  feeding  with  a  medicine 
dropper  or  a  stomach  tube.  Several  times  a  day  we 
use  a  warm  bath  followed  by  the  gentlest  sort  of  mild 
spray,  just  enough  to  make  him  take  a  few  deep  breaths, 
expand  his  chest  muscles,  and  cry,  but  never  to  shock 
him.  We  may  pinch  him  a  little  to  make  him  cry,  and 
under  no  circumstances  let  him  sleep  so  long  that  he 
misses  the  feeding  which  should  come  every  two  hours. 
This  condition  of  atelectasis  is  a  source  of  frequent 
death  in  tiny  infants,  and  certainly  deserves  your 
study  and  your  consideration. 

IV.  The  group  due  to  constitutional  factors  has  par¬ 
ticularly  been  emphasized  by  the  European  schools. 
First  and  foremost  is 

a.  The  condition  known  as  Spasmophilia,  which 
means  simply  tendency  toward  spasms.  This  group  is 


168 


of  ever  growing  importance  in  our  daily  practice.  One 
would  suspect  Spasmophilia  with  a  history  of  artificial 
feeding  or  of  prolonged  breast  feeding  without  the  addi¬ 
tion  of  other  food.  Either  one  of  these  two  factors  pre¬ 
disposes  to  rickets,  with  which  Spasmophilia  is  closely 
associated.  With  such  a  history  and  when  examination 
shows  the  beading  of  the  ribs  known  as  the  Rosary,  or 
shows  softness  of  the  bones  of  the  skull-craniotabes,  we 
would  be  justified  in  suspecting  this  condition.  Mani¬ 
festations  as  described  by  the  mother  are  three:  First, 
the  baby  crows.  Hot  every  case  of  crowing  of  a  child 
is  due  to  Spasmophilia,  but  its  occurrence  should  make 
us  suspicious.  This  crowing  is  due  to  spasm  of  the 
muscles  of  the  larynx,  technically  called  Laryngo 
Spasm.  The  second  manifestation  is  an  out-and-out 
convulsion.  Laryngo  spasm  and  convulsion  are  char¬ 
acteristic  in  the  fat,  pasty,  overfed  child.  The  under¬ 
nourished  baby  fed  on  condensed  milk  or  barley  gruel 
is  more  likely  to  show  a  generalized  rigidity,  not  of 
sudden  appearance,  but  of  chronic  duration. 

The  diagnosis  of  this  condition  is  made  from  the 
above  history  and  physical  examination.  Examination 
demonstrates  the  nature  of  the  underlying  condition, 
namely,  an  increased  irritability  of  the  nervous  system, 
both  to  mechanical  and  electrical  stimulation.  Three 
symptoms  are  induced  by  mechanical  means : 

1.  The  Chvostek  or  Facial  Phenomenon.  This  con¬ 
sists  of  tapping  lightly  with  your  finger  or  with  your 
percussion  hammer  over  the  facial  nerve.  If  one  taps 
over  the  branch  going  to  the  eye  muscles,  these  will 
contract.  If  one  taps  over  the  lower  branch  enervating 
the  muscles  of  the  mouth,  these  respond. 

2.  The  Trousseau  sign — putting  a  rubber  band  or 
simply  employing  your  fingers  to  tightly  encircle  the 
upper  arm — makes  a  classical  picture.  The  constric¬ 
tion  must  last  about  two  minutes  and  must  be  sufficient 
to  cause  a  definite  anemia  of  the  lower  arm.  When 
positive,  the  test  shows  the  hand  tightly  clenched  in  the 
.so-called  obstetrical  position,  namely,  flexion  of  the 
fourth  and  fifth  fingers,  extension  of  the  first,  second, 
and  third ;  the  so-called  Obstetrician’s  hand.” 

3.  The  peroneal  is  the  most  delicate  of  the  three 
mechanical  tests.  Tap  lightly  upon  the  nerve  as  it 
emerges  around  the  head  of  the  fibula.  In  cases  of 


169 


Spasmophilia  the  muscles  enervated  by  the  peroneal 
will  contract  and  the  foot  jerks  laterally  and  dorsally. 

4.  Many  children,  however,  are  in  a  state  of  Spas¬ 
mophilia,  hut  still  do  not  show  these  three  tests.  Here 
the  diagnosis  can  be  made  only  by  the  use  of  an  elec¬ 
trical  apparatus.  Don’t  get  excited,  gentlemen.  This 
sounds  complicated,  but  is  really  very  simple.  Those 
of  you  who  are  doing  much  children’s  work  should  cer¬ 
tainly  get  an  electrical  machine.  Taking  these  reac¬ 
tions  requires  about  two  minutes  time.  Simply  place 
the  cathode  over  the  median  nerve,  open  and  close  the 
current,  and  if  the  muscles  of  the  hand  contract  with 
less  than  five  milliamperes  a  diagnosis  of  Spasmophilia 
can  be  made.  It  is  unnecessary  to  go  much  over  five 
milliamperes,  for  the  child  may  suffer  pain.  If  con¬ 
tractions  do  not  result  from  this  strength  of  current, 
the  child  is  not  in  a  condition  of  Spasmophilia. 

The  treatment  of  this  condition  is  that  of  the  under¬ 
lying  rickets.  Diet  must  be  carefully  corrected.  Phos¬ 
phorated  Cod  Liver  Oil  may  be  given  in  doses  of  one 
teaspoon  three  times  daily.  During  the  days  or  weeks 
required  to  relieve  the  child  until  the  nervous  system 
again  becomes  normal,  convulsions  are  apt  to  recur. 
The  treatment  of  the  immediate  convulsion  is  along  the 
lines  which  we  laid  out  at  the  beginning  of  the  lecture. 
A  valuable  aid,  however,  in  our  therapy  is  the  use  of 
calcium  bromide  in  doses  of  Gr.  XY  daily.  Ludwig 
F.  Meyer  recommended  this  drug  for  two  purposes,  the 
calcium  overcoming  the  rachitic  tendencies  and  the 
bromide  acting  as  a  depressant  to  the  nervous  system. 

How,  gentlemen,  to  return  to  the  reflex  causes  of 
convulsions :  phimosis,  dentition,  and  worms.  The  pres¬ 
ent  tendency  among  the  men  who  have  had  greatest 
experience  with  Spasmophilia  is  to  regard  those  cases 
of  convulsions  occuring  from  reflex  causes  as  cases  in 
which  the  underlying  factor  has  been  this  constitutional 
change  of  Spasmophilia.  Reflex  irritation  certainly 
does  not  cause  spasm  in  every  baby,  but  will  be  suffi¬ 
cient  to  produce  this  symptom  in  a  child  with  a  con¬ 
stitutional  predisposition.  In  the  same  way  perhaps 
those  children  who  suffer  a  convulsion  at  the  onset  of 
an  infectious  disease  are  also  predisposed.  You  see, 
gentlemen,  with  this  conception  what  gross  neglect 
we  are  guilty  of  when  we  say  in  an  offhand  way,  “The 


170 


baby  is  teething  and  needs  bis  gums  lanced.”  You  will 
be  surprised  in  bow  many  cases  your  mecbanical  and 
electrical  tests  will  show  that  the  fundamental  fault 
lies  in  the  baby’s  constitution. 

b.  Epilepsy  is  recognized  more  and  more  frequently 
in  children.  Without  the  use  of  the  electrical  machine 
one  would  hesitate  making  the  diagnosis  in  a  small 
infant,  for  many  of  these  spasms  will  be  due  to  Spas¬ 
mophilia.  On  the  other  hand,  the  electrical  tests,  if 
made,  readily  will  differentiate  the  two,  epilepsy  not 
showing  the  heightened  electrical  irritability.  The  his¬ 
tory  of  the  epileptic  attack  also  is  characteristic.  Thq 
child  is  either  from  alcholic  parents  or  from  parents 
with  grave  nervous  disorder.  The  convulsion  itself  is 
typical.  An  aura  warns  the  child  of  the  impending 
attack.  The  onset  is  sudden,  with  a  tonic  spasm.  Fol¬ 
lowing  this  come  the  clonic  jerking  movements.  During 
this  stage  the  child  froths  at  the  mouth,  bites  the 
tongue,  often  urinates,  and  has  a  bowel  movement.  Then 
follows  a  deep  sleep. 

These,  gentlemen,  are  the  main  causes  of  convul¬ 
sions  in  children.  I  am  going  to  give  you  a  little 
scheme  which  may  help  you  toward  a  quicker  diagnosis. 
When  you  are  called  in,  when  the  family  is  in  furor, 
when  mother,  grandmother,  aunts  and  uncles  are  urg¬ 
ing  you  to  “Do  something,”  if  you  sit  down  and  say, 
“I  would  like  half  an  hour  to  study  this  out,”  you  will 
not  last  long  in  the  family.  You  must  at  any  rate  give 
grandmother  some  definite  information,  and  for  this 
purpose  this  little  outline  may  be  of  value: 

1.  During  the  first  month  of  life  the  most  likely 
causes  are : 

a.  Meningeal  hemorrhage, 

b.  Cerebral  malformations, 

c.  Acute  meningitis, 

d.  Atelectasis. 

As  you  see,  gentlemen,  these  are  all  grave  factors. 
Hemorrhage,  if  it  does  not  result  in  immediate  death, 
gives  rise  to  brain  injury  which  manifests  itself  later 
by  feeble-mindedness  and  the  general  picture  known  as 
Little’s  disease.  Malformations  mean  idiocy.  Menin¬ 
gitis  in  the  new-born  is  most  severe,  and  atelectasis 
occurs  only  in  conditions  of  marked  weakness  and 
debility. 


171 


After  tlie  first  month  up  through  the  second  year  the 
most  likely  causes  are : 

a.  If  the  baby  be  rachitic,  spasmophilia, 
h.  Always  keep  in  mind  the  onset  of  acute  infectious 
disease,  and  where  convulsions  are  very  severe,  not  re¬ 
sponding  readily  to  treatment,  beware  of  a  meningitis. 

c.  Spoiled  food  is  always  to  be  considered.  This  may 
be  the  most  important  in  this  section  of  the  country, 
although  Dr.  Summerell  informs  me  that  the  febrile 
stage  of  malaria  almost  invariably  is  accomplished  by 
severe  convulsions  in  his  practice. 

Over  two  years  of  age  the  above  factors  must  he  con¬ 
sidered,  and,  in  addition,  epilepsy  becomes  more  and 
more  prominent.  Convulsions  starting  in  after  the 
second  year  of  life  are  far  more  likely  to  be  epilepsy 
than  spasmophilia.  At  this  age  the  rarer  causes  of 
convulsions  must  meet  with  our  consideration.  Occa¬ 
sionally  will  a  brain  tumor  or  brain  abscess  be  the 
etiological  factor. 

Gentlemen,  this  ends  the  subject  of  convulsions.  As 
you  see,  it  is  no  small  problem,  covering  almost  the 
whole  field  of  medicine.  This  lecture  is  barely  an  out¬ 
line  to  guide  you  in  further  study.  If  I  have  impressed 
upon  you  that  a  convulsion  is  a  symptom  and  not  a 
disease ;  if  I  have  shown  you  that  when  you  have  treated 
a  convulsion  your  work  is  not  finished,  but  is  just  com¬ 
mencing,  I  shall  be  most  happy  indeed. 


